Authorized Prepayment Form - North Durham Professional Counsellors

Please Fill The Form Below

Please note that we require a credit card on file to begin services at North Durham Professional Counsellors even though you may choose to pay by E-Transfer or by Cheque or Cash if receiving in-person services.
I*
authorize North Durham Professional Counsellors to process payment on my Visa / Master Card upon completion of psychological and/or psychotherapy services if not paid through other methods of payment. Please note as per our fee policy, we require 48 hours cancellation notice or full fees will be charged.
Client Name (s) Associated with this Account*
Charged Hourly Rate for Services: $ Per Hour*
Type of Card
- Visa
- Master Card
Please note we do not accept Debit Visa or American Express
Name on Card*
Card Number:*
Expiry Date*
CVV#*
Invoice Addressed To*
Email Address for Electronic Billing*
Billing Address and Postal Code*
Signature of Client*
Date*