Certificates in: Play Therapy, Sexual Abuse and Trauma Recovery,

Marriage and Family Therapy, and

Canine Assisted Therapy
Licensed Mental Health Counselor MH 9099
924 N. Magnolia Ave, Suite 210 p 407. 312.8295
Orlando, FL 32803 f 407.704.7999
ehollingsworthlmhc@gmail.com

Credit Card Authorization

I authorize Elizabeth R. Hollingsworth, MA, LMHC and Hollingsworth, Hope Can Heal
Counseling Center or Hollingsworth Counseling Center, LLC to charge the following
credit card $_________ for the assessment, $_______ for each individual session. The no
show fee is the full cost of the session that will be charged to this card at the time of
your appointment.

Card Type: Visa Mastercard Discover

Name on card:____________________________________________________________

Card Number:____________________________________________________________

Expiration date:___________________________________________________________

Verification code (3 digits on back of card)_____________________________________

Billing address: __________________________________________________________

Street Address
________________________________________________________________________
City State Zip
Signature:_______________________________ Date:___________________________

This authorization may be cancelled by client at any time by providing rescission of

authorization to use credit card in writing. No other form of rescission will be accepted
or be considered valid. Client agrees that prior to any rescission of the credit card
authorization, Elizabeth R. Hollingsworth, MA, LMHC and, Hope Can Heal Counseling
Center or Hollingsworth Counseling Center, LLC, may ensure the clients balance due, if
any, is satisfied by the credit card listed above, unless some other form of payment is
made.

2017