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OUR LOCATION

4777 Lakeland Highlands Road
Lakeland, FL 33813

Phone: 863.647.3518
Fax: 863. 646.7738

 

OFFICE HOURS

Monday - Thursday
8:00 AM to 5:00 PM
Fridays
8:00 AM to 12:00 PM
Closed on Holidays

HP Counseling

Credit Card Authorization Form

Name *
Name
Billing Address for Card *
Billing Address for Card
By typing my electronic signature below, I certify that I am an authorized signer of the credit card detailed above. I authorize Highland Park Counseling Center to charge my card for late cancel/no-show fees as stated in the Mission and Policy Statement. I understand that my card will be charged my agreed upon rate up to $55. I will be provided a copy of my receipt either by hand-delivery at my next appointment, mail, or electronically at my discretion.
I wish to receive my receipts: *