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Special Payment Arrangement Request

At Trust Children, we understand that each family’s circumstances are unique.

This form records any change to our standard payment process, as required by your Service Agreement:
“Any changes to fees will be agreed upon in writing by both parties.”

Structure of the Arrangement

Each special payment arrangement is converted into a therapy case equal to six (6) hours of clinician time.

A case represents a complete therapy block; including both direct time (therapy with your child) and indirect time (clinical note-taking and follow-up to support ongoing care).

Session lengths may vary (for example, 1, 1.5, or 2 hours), but together they total six hours.

Each case is invoiced before the first session to keep payments simple and consistent for families.

Untitled checkboxes field

I understand the structure of this arrangement.

Administrative Contribution

A 13% administrative contribution applies to this arrangement.
This contribution supports the additional coordination, tracking, and accounting time required to manage customised payment schedules.
It also helps reduce the administrative load for families by ensuring invoicing and payments are streamlined.

Untitled checkboxes field

I understand that a 13% administrative contribution applies to this arrangement.

Agreement

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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.

Special Payment Arrangement Request

Structure of the Arrangement

Administrative Contribution

Agreement

Parent / Caregiver name

Child name