Page 1 of 2
Special Payment Arrangement
Please check to indicate your agreement with the following.
At Trust Children, we understand that each family’s circumstances are unique.
*
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
*
Service Agreement variation
Our service agreement requires that changes are agreed upon in writing by both parties.
Structure of the Arrangement
*
Structure of the Arrangement
Each special payment arrangement is converted into a therapy block (case) equal to six (6) hours of clinician time.
Each case will be invoiced before the first session to keep payments simple and consistent for families.
Administrative Contribution
*
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
Untitled checkboxes field
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 understand I can request to revert to Trust Children standard payment process at any time.
Parent / Caregiver name
*
Child name
*
Submit
