I authorize Allied Behavioral Health Services, Incorporated to charge the credit card indicated in this web form, for the noted amount on today's date. I understand that returns, refunds and cancellations are subject to Allied Behavioral Health Services, Incorporated's terms & conditions. I certify that I am an authorized user of this credit card and that I will not dispute the payment with my credit card company, so long as the transaction corresponds to the terms indicated in this web form.