Third Party Payment Authorization

Third-party payment authorization allows someone other than yourself to cover the costs of the services you receive at Your Counselling Ltd. With this authorization, the designated third party will be notified of your attendance for billing purposes only, ensuring confidentiality. No additional information about your sessions or personal details will be disclosed. This arrangement offers a convenient way to manage payments while maintaining privacy and confidentiality in counselling services.

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Statement of Understanding: Third Party Payment

This authorization form allows Your Counselling Ltd. to collect payment from the specified third party on your behalf for any outstanding balance. By completing this form, you acknowledge that the third party will be informed of your attendance in counselling but will not receive any additional information beyond confirmation of attendance.

Client File Name *

First

Last

Client Contact Phone *

Understanding:

Client Contact Email *

Client Date of Birth *

Third Party Payer Information *

First

Last

Relationship to Client *SelectGuardianParentSpouseSiblingFriendEmployerOther

Email of Third Party Payer *

Authorization

I hereby authorize Your Counselling Ltd. to collect payment on my behalf from the above noted third party. I understand I am responsible for the payment of any balance not paid for on my behalf.

Click to indicate agreement

• Yes

Signature

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