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UBC Psychology Clinic Online Payment Form
UBC Psychology Clinic Online Payment Form
Name
*
First
Last
Email
*
Service
Service
*
Select
Individual therapy session/assessment
Group therapy session/assessment
Psycho-educational Assessment
Invoice Number
*
Individual Therapy
--
$15.00
$20.00
$35.00
$50.00
Missed Session $10.00
Other:
Select Fee according to your signed Fee Agreement with the UBC Psychology Clinic
Other Individual Therapy Amount
Group Therapy
--
$10.00
$20.00
$30.00
$50.00
Missed Session $10.00
Other:
Select Fee according to your signed Fee Agreement with the UBC Psychology Clinic
Other Group Therapy Amount
Psycho-educational Assessment
--
$360.00
$600.00
$840.00
$1,000.00
Other:
Select Fee according to your signed Fee Agreement with the UBC Psychology Clinic
Other Psycho-educational Assessment Amount
Total
$0.00
Please note that all payments are non-refundable. After you click Submit below and enter your payment details on the next page, you will see a "Payment Receipt" page. Please print that receipt for your records.
Name
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