Credit Card Authorization

I authorize Insights Group and its representative to charge my credit card/HSA card after each scheduled session at the agreed-upon rate. I also authorize my account to be charged for a late cancellation (24 hours or less from the time of the scheduled appointment) or a “no show” appointment at the full session rate.

Your form submission will automatically be sent to our billing department and Insights Group’s Executive Assistant will contact you to input credit card information into our secure system.

Name of Client (or Personal Representative)*
First Last
Email*
Phone*
Relationship to Client
Date*
MM slash DD slash YYYY
Signature of Client (or Personal Representative)*
Name
This field is for validation purposes and should be left unchanged.

Please wait for the confirmation before closing out of the form.