Credit Card Payment Authorization

As a courtesy, we offer our clients the option for their session fees to be charged directly to their credit card.  The Credit Card Payment Authorization form allows MCPST Management Corporation to bill your credit card for services.  This form is kept confidential and private.  If you would like to set up this kind of payment, please complete this form and bring it with you to your appointment.  You may opt out of this service at any time.  If you have any questions about this form, please contact our Office-Billing Manager DeLynn at (608) 237-8004.

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Midwest Center for Psychotherapy & Sex Therapy · 6300 University Avenue, Suite 125 · Middleton, WI 53562 · (P) 608-237-8000 · (F) 608-237-8005