Sign and complete this form to authorize Southern Therapy Solutions to make a monthly charge to the credit card listed below. The card will run on the last business day of each month. By signing this form, you give us permission to debit your account for the amount indicated on your monthly statement. This permission for a once monthly transaction and does not provide authorization for any additional unrelated debits or credits to your account.

I , the parent or guardian of , authorize Southern Therapy Solutions to charge my credit card account indicated on my monthly statement. This payment is for Speech, ABA, Occupational Therapy or Dietary Services at Southern Therapy Solutions.