Authorization to Keep Card on File
I hereby authorize Larissa Brown, MS to charge my account $25 for a non-refundable deposit that will reserve my spot in the next EmpowerME support group.
Choose one of the following payment options:
I hereby authorize Larissa Brown, MS to charge my account $750 for payment in full for the next EmpowerME support group.
I hereby authorize Larissa Brown, MS to charge my account automatically each month for the EmpowerME: Women’s Trauma Recovery & Empowerment Group of Maine. Card will be charged the FIRST week of each month for prior month fees of $25 per group meeting.
Participant Full Name
Participant Email Address
Full Name on Card
Billing Email Address
Address Line 1
Address Line 2
I understand that I may attend the first four sessions without commitment and that if I choose to continue past the fourth session I am committing to the full 35-week program and will be responsible for this payment even if I am no longer able to attend meetings.
Being the authorized cardholder, by signing above I understand and agree to the terms set forth in this agreement, agree to pay, and specifically authorize to charge my credit card for the services provided. I further agree that in the event my credit card becomes invalid, I will provide a new valid credit card upon request, to be charged for the payment of any outstanding balances owed.
Charges made for actual services performed by our office are non-refundable.
86 Main Street, Suite 302B
Auburn, ME 04210
619 Brighton Avenue
Portland, ME 04102