Credit Card Authorization – Help with Solutions

Credit card authorization & AutoPay form

Thank you for choosing Solutions Counseling. Please enter your credit card information into our secure form below. Contact Customer Service at 763-515-4563 or questions@helpwithsolutions.com with any questions:

Client Name(Required)

First Last

Client ID (if available)

Name on Credit Card(Required)

First Last

Name of Person Completing this Form(Required)

First Last

Credit Card Information(Required)

American Express

Discover

MasterCard

Visa

Card Number

Expiration Date

Security Code Cardholder Name

Credit Card Billing Address(Required)

Street Address Address Line 2 City State ZIP Code

Phone(Required)

Email(Required)

Enter Email

Do you wish to receive statements by mail?

Yes

We do not offer electronic delivery of statements at this time.

What day of the week follows Wednesday?

Sunday

Monday

Thursday

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