CENTUS Counseling, Consulting & Education : Counseling : Payment Form

Payment Form

Thank you for using our electronic payment option. If payment is for more than one date of service, please describe in the space for addtional comments.

CLIENT INFORMATION

Title:

First Name:

Last Name:

Address (Line 1):

Address (Line 2):

City:

State:

ZIP:

Country:

Phone:

A payment acknowledgement will be emailed to the email address specified below. We respect your desire for privacy and will not share your email address with third parties.

Email Address:

TYPE OF SERVICE

This payment is for:

	Therapy
	Workshop
	Testing
	Deepening Intimacy Seminar
	Benchmark-Walk in the Park
	Other

If Payment Is For Therapy

Clinician Name:

Date of Services:

Additional Comments:

If Payment Is For Workshop

Name of Event:

If Payment Is For Testing

Clinician Name:

Date of Services:

If Payment Is For Other

Description:

Date of Services:

Please enter the name of the person who received our services in the field below if this payment is for a minor or on behalf of someone else.

Recipient Name:

(FIRST, LAST NAME)

YOUR PAYMENT

Payment Amount:

CREDIT CARD INFORMATION

Credit Card Type:

Card Number:

Card Expiration Date:

(Month and Year)

Cardholder's Name:

Colored fields indicate required information.