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Special Payment Arrangement
Please check to indicate your agreement with the following.
At Trust Children, we understand that each family’s circumstances are unique.
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At Trust Children, we understand that each family’s circumstances are unique.
This form requests a change to Trust Children's standard payment processes.
Service Agreement variation
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Service Agreement variation
Our service agreement requires that changes are agreed upon in writing by both parties.
Structure of the Arrangement
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Structure of the Arrangement
The special payment arrangement is for a therapy block (case) equal to six (6) hours of clinician time.
The special payment arrangement is for an assessment module +/- a report (as discussed with my clinician).
Each case will be invoiced at the time of the first scheduled session to keep payments simple and consistent for families.
Administrative Contribution
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Administrative Contribution
A 13% administrative contribution applies to each arrangement.
This contribution supports the additional coordination, tracking, and accounting time required to manage customised payment schedules.
Agreement
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Agreement
I have read and understood the details above
I agree to the terms of this Special Payment Arrangement
I acknowledge this form is a written variation to my Service Agreement
I acknowledge this form is a written variation to my Service Agreement
I understand I can request to revert to Trust Children standard payment process at any time.
Untitled checkboxes field
I understand I can request to revert to Trust Children standard payment process at any time.
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Parent / Caregiver name
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Child name
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Submit
