If you are a self-pay client or have copays/deductibles and you put a card on file, you authorize charges to your credit card through Stripe via SimplePractice for services rendered. These charges will appear on your bank/credit card statement as BluegrassBH. You have the right to request a paper copy of this document. You authorize Bluegrass Behavioral Health & Consulting Services PLLC to charge my credit card through Stripe and agree that my credit card can be charged for any session that is not cancelled at least 24 hours prior to the scheduled session.

I understand that this authorization will remain in effect until I cancel it in writing, and I agree to notify Bluegrass Behavioral Health & Consulting Services in writing of any changes in my account information or termination of this authorization.

I certify that I am an authorized user of this credit card and will not dispute these scheduled transactions with my bank or credit card company as long as the transactions correspond to the terms indicated in this authorization form. I acknowledge that credit card transactions could be linked to Protected Health Information.

Thank you for your interest in services provided by Bluegrass Behavioral Health & Consulting Services.

Please note, that this website and /or the messaging feature is not intended for emergency use, or to seek advice on medical issues. If you are seeking treatment, please call the phone number to schedule an appointment. If you are experiencing a medical emergency or are having thoughts of hurting yourself or others, please call 911, or go to the nearest emergency room.