TheraPay Single Payment Form

1
Customer ID
2
SEC Code
3
Transaction Type
4
What are you paying for today?* This field is required.
Please Select
Please Select
Room Rental
Facilitator Fees
Room Rental + Facilitator Fees
Medicine
Event
Referral
Other
5
What is the name of your Facilitator?If you don't know or don't have one just leave this blank.
6
What is the total payment amount?* This field is required.
7
Project Circle Accepts E-Checks for PaymentPlease either login to your online banking to find your account and routing number, or find a check and use the information from the bottom of your check as shown below.
8
E-Check Information* This field is required.Your security is our priority. We use secure e-checks with 256-bit encryption and TLS for complete data protection. Transactions are processed through an NCUA-accredited financial institution for maximum reliability and trust.
Please Select
Please Select
Checking
Savings
Account Type
First and Last Name of the Account Holder
9-digit ABA Routing Number
Account Number
9
How do we get in touch with you?* This field is required.
Email
Phone
10
Signature* This field is required.By signing below you authorize the payment services provider for Project Circle (TheraPay LLC), to initiate ACH debits from the bank account you have provided for services rendered and applicable fees. You also affirm that you have reviewed and approved the TheraPay Terms of Service available at therapay.org.
Clear
11
Please verify that you are human* This field is required.
Should be Empty: