Schema Therapy
Schema Material Order Form
If you'd prefer to order through our faster, secure Online Credit Card Ordering system, please click here. Otherwise, please complete this form and mail to: Schema Therapy Institute, 130 West 42nd St., Ste. 501, New York, NY 10036. If you'd prefer to fax the form, our fax number is: 212-221-1818.
Mailing Address: Today's Date ___________
Name ______________________________________________________________
Street ______________________________________________________________
City _______________________ State / Province __________ Zip / Mailing Code _____
Country __________ Day Phone ________________Fax Number _________________
E-Mail Address ____________________________ Highest Professional Degree_________
Field of Work______________ Material Is For: __ Clinical Use __ Research __ Personal Use
I want to order (write in quantity next to each):
Schema Inventory Packet: ___ Includes US Shipping: $25 (USD) ___ Includes Foreign Shipping: $35 (USD)
Complete Schema Packet : ___ Includes US Shipping: $40 (USD) ___ Includes Foreign Shipping: $55 (USD)
(including Schema Inventories)
Permission to Reproduce Only (automatically included in both packets above; with this option, you will not receive any forms):
_____ Permission for Schema Inventories Only (US or Foreign): $20 (USD)
_____ Permission for Complete Schema Packet (US or Foreign): $30 (USD)
TOTAL AMOUNT DUE $ _______ (USD)
PAYMENT MUST BE MADE IN US DOLLARS ONLY, OR WE CANNOT PROCESS YOUR ORDER.
WE CANNOT ACCEPT CHECKS BASED ON FOREIGN CURRENCY.
I will pay by:
___ Visa ___ MasterCard ___ American Express ____ Discover
___ Check Payable to "Schema Therapy Institute" (we ship when check clears)
___ Other Form of Payment (Explain: ____________________________________)
If using credit card:
Name on Card _______________________________ Credit Card Number________________________
Expiration (Month/Year)___________ Verification Code ______________
Everyone must sign:
I agree to all the terms outlined on the Schema Therapy site related to this purchase, especially under Permission to Use and How to Purchase.
I also agree that I am authorizing the Total Amount Due above to be billed to my credit card (only applicable if credit number is supplied above).
Signed ___________________________________________________________
Billing Information (only if different from mailing information above):
Name ____________________________________________________________
Street ____________________________________________________________
City ____________________ State / Province _______ Zip / Mailing Code __________
Country __________ Day Phone _________________ Fax Number ______________
Other Comments or Special Requests:
__________________________________________________________
__________________________________________________________
__________________________________________________________