Please complete all fields below. You may cancel this authorization at any time by contacting Gayle Saifert and Compass for Life. This authorization will remain in effect until cancelled.
authorize Gayle Saifert and Compass For Life to charge my credit card for service rendered. By signing this form, I agree to allow my credit card to be charged for services delivered by Gayle Saifert and Compass for Life. including therapy appointments, non-session fees (phone calls, written documentation and consultations with allied professionals over 15 min), missed appointments and cancellations that did not allow for 48 business hours notice (cancellation notice must be provided Monday-Friday) I agree to have my credit card information stored with Stripe and Owl Practice. I have the right to cancel this agreement at any time.Credit card information will be deleted at the time of request.
Fee Schedule Breakdown:
Paid by Visa or Mastercard
Initial intake session- pro-rated session fee (1 hour-1.5 hours)
Individual Session (50 minutes)
Missed appointment or cancellations without 48 business hrs (Monday-Friday) cancellation notice will be billed at the regular session rate
Family Session (60 minutes)
Professional Consultation with allied health professional and teachers/guidance counsellors pro-rated at the individual session rate
Telephone calls with parents/caregivers beyond 15 minutes, will be pro-rated at the individual session rate
Clinical letters/notes prorated at the individual session rate