Fees, cancellations and payment

Fee Agreement

This sets out session fees, the cancellation policy and how payment is handled. Please read it carefully and ask any questions before signing.

Client details

Name

Date of birth

Contact phone

Address

Fees and payment

Appointments cancelled with less than 48 hours' notice, or missed appointments, may incur the applicable cancellation or no-show fee.
Service	Fee	Notes
Initial assessment session (90 min)	$220	Medicare rebate available
Standard therapy session (50 min)	$180	Medicare rebate available
Extended session (75 min)	$220	Medicare rebate available
Cancellation	$85	Applies if less than 48 hours' notice
No-show (failure to attend without notice)	$180	Medicare rebate unavailable

Payment timing

Payment is due at the time of service unless otherwise agreed.
For telehealth sessions, payment must be received prior to the session.

Medicare rebates

Clients attending under a Mental Health Treatment Plan are responsible for paying the full session fee at the time of their appointment. Medicare rebates can be processed at the conclusion of your appointment once payment has been received.

Fees are reviewed periodically and clients will be notified in advance of any fee changes.

Payment authorisation

I hereby authorise Ember & Oak Therapy to charge my nominated payment method for the agreed fees related to therapy services, including session fees and any applicable cancellation or no-show fees. I understand that:

Payments will be processed at the time of service or as otherwise agreed.
In case of cancellation fees, I authorise the charge if cancellation policy terms are not met.
It is my responsibility to ensure sufficient funds or credit are available.
I may revoke this authorisation by providing written notice prior to the next scheduled payment.
Payment details may be securely stored through Ember & Oak Therapy's practice management system for the purpose of processing session and cancellation fees, where applicable.

Card details are never collected through this website. They are taken directly in the practice management system.

Agreement

Please tick each statement to indicate your agreement.

I agree to provide at least 48 hours' notice for cancellations or rescheduling.

I understand that cancellations or missed appointments without adequate notice may incur the cancellation fee.

I authorise Ember & Oak Therapy to charge my nominated payment method as described above.

I understand that I pay the full session fee at the time of my appointment, and that any Medicare rebate is processed afterwards.

I have had the opportunity to ask questions about this fee agreement and understand my financial responsibilities as a client of Ember & Oak Therapy.

I have read and understood this fee agreement and agree to the terms outlined above.

Signature

Typing your full name below acts as your electronic signature. The date and time of signing are recorded automatically when you send this form.

Type your full name to sign

Is the client under 18 years of age?

NoYes

Parent or guardian

Where the client is under 18, the parent or guardian responsible for payment should sign this agreement.

Parent/guardian name

Relationship to client

Phone

Type your full name to sign

Your answers are emailed straight to Amy Inglis and are not stored on this website. Email is convenient but never completely secure — if you would rather not send something in writing, leave it blank and raise it in session instead. How your information is handled is set out in the privacy policy.

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