Update Payment Information Form

Please note you can also update this information on your TherapyNotes portal at any time. Your therapist is also equipped to help you in updating this information.

Zarandona Counseling offers this digital form, made for ease of access and convenience, for you to be able to quickly and effectively update your preferred payment method.

This form only collects the information requested above. All information requested is kept secure. After receiving your information, it will be transferred to your file and updated in our systems before being deleted from our responses collection storage.

If you have any questions, reach out to our team through contact@zarandonacounseling.com. Or speak with your therapist and they can assist you as well.

It is critical your payment information be kept up to date. Without a credit card on file, an outstanding balance would interfere with the continuation of your care.

Therapist

Patient Name

First Name

Last Name

Name on Credit Card

Credit Card Number

Type of Card (Visa, Mastercard, Discover, Amex, etc...)

Expiration Date

Security Code (CVV)

Billing Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone Number

(###)

###

####

Acknowledgment

Zarandona Counseling may utilize my payment methods on file for any balances, including late cancellation and no-show fees, without additional authorization.

Update Payment Information Form

Contact us

Address

Text/Voicemail

Fax

Due to the high volume of inquiries, please use our contact form to receive the most expedited reply.