I authorize The Arizona Relationship Institute to keep my credit/debit card and/or checking account information and signature on-file in-order to charge my credit/debit card and/or checking account for balances due.

I acknowledge that payment for the initial session is taken in advance and not at the time of service. I further acknowledge that in the event that the session lasts longer than the scheduled time period, the rate for the extra time will be billed at a prorated for the fee per hour in 15-minute increments, and I agree to pay for the full time used for my sessions.

I authorize the credit card given at the time of the initial intake to be on-file and for the Arizona Relationship Institute to charge this card at the rate stated in my Client Contact Form, according to the amount of time scheduled and any extra time I incurred from my appointment under the following circumstances:

1.) Services within less that 24 Hours of my scheduled time.

I agree to pay the full amount for the time scheduled, even in the event that I late-cancel or no-show. I also authorize a fee of $35 to be charged if a check payment is returned due to insufficient funds, and a $35 fee for failure to return book(s) [Per Book] borrowed from any therapist at The Arizona Relationship Institute within 30 days of receipt of written request that a book be returned.