Cherish Payment Form

Name of the client*

First NameLast Name

My Products*

Cherish Connect: Accommodating Neurodivergence in RamadanThursday, March 6th, 7:30pm

$5CAD

Screening DepositFor pediatric screening service

$160CAD

D-I-Y Adult Autism Screening Complete the screening at your own pace

$400CAD

Sensory Screening DepositThis is the non-refundable deposit for sensory assessment. If you are accessing this service through third-party funding, you are not required to make the deposit.

$500CAD

Speech Assessment DepositThis is the non-refundable deposit for speech assessment. If you are accessing this service through third-party funding, you are not required to make the deposit.

$500CAD

Psychoeducational Consult Deposit This Service is a non-refundable deposit for psychoeducational consultation. If you are accessing this service through third-party funding, you are not required to make a deposit.

$500CAD

Subtotal

$0.00CAD

Tax

$0.00CAD

Total

$0.00CAD

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

E-mail*

example@example.com

Billing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Date

Purchase date

What service

DIYdeposit