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Credit Card Authorization Update Form:

Welcome to our secure credit card re-authorization form:

Firstly, if you are a new client, you are almost certainly at the wrong form. Please proceed to our Full Consent Forms and complete them prior to your first session.

This form is for previously existing clients only.

"Existing clients" means clients who have already completed our three required intake forms: our Standard Consent, Virtual Therapy Consent, and Credit Card Authorization, and have already attended their first counselling session in-office or virtually.

 

This form exists for situations where, due to simple credit card expiration, compromised credit cards or other reasons, a need has arisen to replace a means of payment. It modifies an existing agreement to Psychological Counselling, rather than replacing or substituting for it.

To provide the highest standard of privacy currently available, we encrypt all of our forms using SSL and then add a second layer of Public Key Encryption using PGP technology - ensuring the complete security of your credit card information both at rest and in transport.

Credit Card Authorization Form

The contents of this form are inputted directly into the incredibly detailed verification system required by our merchant service provider. As such any deviation from the information your credit card company has on file (as displayed on your credit card statement) will cause the registration of your credit card information to fail. Please ensure that the below information exactly matches the information displayed on your current credit card statement.

Identity Verification

(Note: No spaces, dots or dashes)

Address Verification

(Note: No space or dash)

Payment Detail Verification

Credit Card Type:

/

Terms and Conditions

Total amount of payment currently authorized: $249.99/standard 60min session (Including GST where applicable).

Please request a session booking via telephone or e-mail before sending us this form.

This authorization for repeat sessions is considered valid until revoked and a typewritten signature shall be considered as valid as hand-signed.

This secure PGP encrypted form cannot be submitted until you have completed all form fields/checkboxes. If you fail to see a message informing you that your data has been encrypted and sent successfully, please review and complete all missed fields and checkboxes.

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403 819 3545 (Text message capable)

info@henze-associates.com (iMessage capable)

403 819 3545, (Toll Free) 1 877 922 3143

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