I prefer payment by personal checks when possible. Whether you choose to pay by check, cash, or credit card, though, I require one active Visa, MasterCard, or Discover Card number from you that may be used in the event that you are unable to bring cash or a check with you to an appointment.


I/We hereby authorize Allison Villarreal, LPC to charge the credit card listed below at the rate of $100 per session in the event that payment is not made by cash or check at the beginning of the session. I/We also authorize Allison Villarreal to charge the credit card listed below at the rate of $100 if I/we cancel an appointment or initiate a schedule change less than 24 hours in advance of my/our originally scheduled appointment time, or if I/we do not attend a scheduled appointment. I/We understand that the amount charged, the date of charge, and Allison Villarreal’s name will appear on my/our credit report, producing a record of services visible to my/our credit card company. I/We also understand that no specific content of my/our sessions (e.g. diagnosis, treatment plan, session notes) will be disclosed to billing or credit agencies without my/our signed consent. I/We understand that my/our credit card information will be stored in a locked file cabinet during the duration of my/our treatment and for 7 years after therapy termination, at which point all card information will be shredded. I/We also understand that up-to-date encryption programs will be used in all online credit card billing procedures.

Name on Card *
Name on Card