Service and Payment Agreement 2023Service and Payment Agreement • June 28th, 2023
Client Name: Date of birth: Address: This is a (please circle) Permanent Residence/Interim Placement (please provide documentation if there are any court orders in place regarding placement). Parents/Carers: *Please provide documentation if there is a Family & Community Services Care arrangement in place. Contact email: Contact mobile: Name: Number:
SERVICE AND PAYMENT AGREEMENTService and Payment Agreement • April 22nd, 2015
Authorization for Services: By virtue of my signature below, the undersigned hereby authorizes Beth Osten & Associates to provide such assessment and treatment services as may be deemed necessary and advisable for my child. The undersigned (individually referred to herein as “I”) reserve the right to refuse consent in the future to any proposed procedure or service.
Service and Payment AgreementService and Payment Agreement • May 15th, 2020
This agreement refers only to investment related business and does not include providing protection advice. We agree to provide you with services and in return you agree to pay us for our services, as detailed below.
