HOW TO USE YOUR VISA CREDIT CARD TO PAY FOR TELEPHONE SESSIONS WITH DR. WILL CUPCHIK

Simply copy the form immediately below onto your word processing program, print out, and fill in. 

Send this form to Dr. Cupchik by faxing the filled out form to Fax number 416-489-8882

Date: ____________________________

Regarding ___________________________ (name of client),

I, ______________________ (name printed), hereby authorize Dr. Will Cupchik to immediately

charge my VISA credit card, # _______________________________, expiration date ______,

in the name (print, please) _________________________________ printed on the front of the card,

and the security digits _________ printed on the back of the card,

in the amount of the Canadian equivalent of $ ___________ U.S., to be held in trust,

for ___________ (number of) telephone consultation/counselling sessions, 

each ________ fifty (50) minutes in length, that will be provided to

____________________________ (name of client), at the times agreed upon, the first (or only) session(s)

 to be held within seven business days from the date of sending this fax.

My phone number is _________________________.

In the case of telephone sessions, I understand that I will be calling Dr. Cupchik at 416-928-2262

at the agreed-upon time(s).

(signed) ____________________________________

(printed) ___________________________________

Date: _____________________________________

Send this form to Dr. Cupchik by faxing the filled-out form to 416-489-8882