Credit Card Change Form
Please fill in all required fields
  • "I understand and agree that all policies of Jodi Valentine Counseling will apply to this card on file. Should this new card not process for any applicable fees, I understand that any other previously added cards will be processed for such applicable fees".

  • (CVC- 3 digit code on back of card)
  • You will receive an email receipt for any charges applied to your credit card unless otherwise requested. A super bill can also be provided for insurance purposes.
  • Please type your name as you would sign on your card.