Payment Form                                

 

For Individual/Couple/Family services

 

First name: ______________Last name: __________________________Tel. N. _______________

Address: _______________________________________E-mail (optional) ____________________

 

 

For organizations/HR services

 

Name of the company ___________________________________Number of people involved _____

First name of the contact person: ______________Last name: ______________________________

Position __________________Company’s address: _______________________________________

Tel. N. of contact person ______________E-mail ________________________________

 

You would like to book (please mark):

    Service

    Rate /hour

    Min. payment required

    Individual counseling or psychological assessment session

    $110

    $110

    Couple or family counseling or psychological assessment session

    $120

    $120

    Psychological Service for management

    $180

    $180

    Workshop for management (please indicate the topic) ______________________________________________

    $30 pp

    $180

    Psychological Service for employees

    $110

    $110

    Workshop for employees (please indicate the topic) ______________________________________________

    $25 pp

    $150

    Group therapy course, 8 weeks (please, indicate the course):________________________________________

    $25

    $400

    Parenting counseling course, 4 weeks (please indicate the children’s age group, which you are interested in): ___________

    $25

    $200

 

Payment enclosed by:

 

 * VISA: Number ______________________________ Exp. date ____________________

               Name on the card _______________________ Signature: ___________________

 

  * Check payable to Psychological Services for  $______________________

Mail this form with your payment to:

Psychological Services,

92 Bowman St., Hamilton,

ON, Canada L8S 2T6.