Secure Payment

Payment Authorization

Authorize your payment method for coaching services. All information is encrypted and secure.

Client Information

Client Name *

Cardholder Information

Cardholder Name *

Cardholder Email *

Billing Address

Street Address *

City *

State *

ZIP Code *

Card Details

Security Note: For PCI compliance, only the last 4 digits of your card are recorded here. Full card details must be entered through our secure payment processor.

Card Type *

Last 4 Digits *

Recurring Payment

Enable recurring payments for ongoing services

Authorization & Signature

I authorize Mary's Counselor's Couch to charge my card for coaching services as agreed. I understand this authorization will remain active until I revoke it in writing. All charges will appear as "Mary's Counselor's Couch" on my statement.

Signature *

By typing your name, you authorize the payment method above.

Date *