Credit Card Consent Form


Child and Family Psychological Services is able to securely keep credit cards on file.  This can help simplify your payment process!

Clients interested in learning more or adding a card to their account, please call our Billing Department at 781-474-5292 to provide your credit card information and process payment.

Please complete ALL sections of the our consent form.  If you do not indicate a monthly limit amount, $500 will be the default limit charged once per 30 day Billing Cycle.  For your added security please DO NOT write your Credit Card number on the form.

Telehealth Consent Form 


All patients participating in a video Telehealth session should complete this form.