Updated Payment Information Form

Updated Payment Information Form

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Updated Payment Information Form
  • Client Information

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  • Payment Update Consent

  • Credit Card Authorization

    A valid credit card must be kept on file regardless if you selected the Bank Account (ACH) payment option.
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  • I hereby authorize Couples Academy to charge my credit card (information below) consistent with the terms agreed upon in the agreement forms. All payments will take place prior to the start of each session. 

  • Please finalize your Credit Card Update Form by clicking the SUBMIT FORM button below.

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