Electronic Payment Agreement

Innovative Counseling Services, Inc.


If you wish, you may pay fees electronically – through funds transfer or using a payment card -- using any of the following services: Square PayPal or Zelle.

We have a duty to uphold your confidentiality, and thus we wish to make sure that your use of the above payment services is done as securely and privately as possible. After using any of the above services to pay your fees, that service may send you receipts for payment by email or text message. These receipts will include our business name, and would indicate that you have paid for a therapy session. It is possible the receipt may be sent automatically, without first asking if you wish to receive the receipt. We are unable to control this in many cases, and we may not be able to control which email address or phone number your receipt is sent to. In addition to these possible emails or text messages, payments made by credit card will appear on your credit card statement as being made to Innovative Counseling Services.

Please consider who might have access to your statements before making payments by credit card. Health Savings Accounts and Flexible Spending Accounts If you are using a Health Savings Account (HSA) or Flexible Spending Account (FSA) payment card, please be aware that even if your payment goes through and is authorized at the time that we run your card, there is a possibility that your payment could later be denied. In the event of this happening, you are responsible for ensuring that full payment is made by other means.

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Signed by Jean Pollack
Signed On: October 24, 2023

Signature Certificate
Document name: Electronic Payment Agreement
lock iconUnique Document ID: 748699129218f037336baf8dd54282deda1e1a96
Timestamp Audit
November 7, 2021 9:37 am EDTElectronic Payment Agreement Uploaded by Jean Pollack - [email protected] IP 2600:4040:701b:1500:3451:57e0:5a2e:dc45