Counselling Registration and Payment Form

Human Rights Advocates Australia

Counselling Referral form - Therapy For Life
Full Name*

First NameLast Name
Address*

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Street Address Line 2

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Counselling & Natural Healing SessionsConsultations with Cyndi are confidential, professional and usually up to an hour in length. Frequency of consultations will depend upon the style of Counselling utilised and the severity of the problem presented and may be either short-term or long-term.
$80.00AUD Quantity

Total

$0.00AUD
Human Rights Advocates Australia only use bank transfer for payment method. This helps to protect your credit card information online.

Name: HRAA

BSB: 814282

ACC: 51499119

**PLEASE CHECK OVER THESE DETAILS MUTIPLE TIMES BEFORE SENDING PAYMENT TO AVOID AN INCORRECT MONEY TRANSFER.
IFirst Name* Last Name* of Street Address* Address Line 2* City* State* Zip* understand and agree that I am paying for Counselling Services with Therapy For Life.

Refund Policy: Therapy For Life will only provide a partial refund of the Services Fee in the event they are unable to action the Services or if the manager of Therapy For Life makes a decision, at its absolute discretion, that it is reasonable to do so under the circumstances. HRA Australia only receives payments on behalf of Therapy For Life as a third party organisation. All management of the counselling and clients sessions, will be handled by Therapy For Life.
By my signature below, I acknowledge, understand, accept and agree to comply to these terms and conditions.*

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Human Rights Advocates Australia