Billing and Payment Agreement

This agreement sets out the fees for your child’s care and when and how payment is made. Our team will fill in, or confirm, the agreed fees and payment terms with you. All amounts are in Kenya shillings (KES). Fields marked * are required.

1. Client and account details

Child’s full name *Name of person responsible for payment *Relationship to the child *Phone number *Email address for invoices *Billing or postal address (optional)Insurer, employer or sponsor paying part of the fees (if any) (optional)

2. Services and agreed fees

Enter each service with its agreed fee. For a package or monthly plan, enter the package price as the fee and 1 as the quantity.

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Total agreed amount (KES)KES 0

Deposit or advance payment (KES) (optional)Late cancellation or missed session fee (KES) (optional)

3. Payment terms

How fees will be paid *

Invoices are due within this many days of the invoice date *Preferred payment method *Instalment schedule or other agreed terms (optional)

4. Account terms

Invoices and receipts: We issue an invoice for each session, package or billing period, and a receipt for every payment. Payment details for M-Pesa, Airtel Money and bank transfer are shown on each invoice. Please use your invoice number as the payment reference.
Cancellations and missed sessions: Please give at least 24 hours’ notice to cancel or move a session. Sessions cancelled with less notice, or missed without notice, are charged at the late cancellation fee in section 2. We may waive this fee in exceptional circumstances, such as illness or emergency.
Overdue accounts: If an invoice is unpaid 14 days after its due date, we will contact you to agree a way forward. We may pause booking new sessions until the account is up to date or a payment plan is agreed.
Insurers and sponsors: Where an insurer, employer or sponsor pays some of the fees, you remain responsible for any amount they do not pay, including excesses, co-payments and declined claims. We will provide the invoices and reports you need to claim.
Prepaid fees and refunds: If therapy ends early, prepaid fees for sessions not yet provided will be refunded or credited to your account within 30 days, less any amount you owe.
Fee changes: We give at least 30 days’ written notice of any change to our fees. The price of a prepaid package does not change during that package.
Billing questions: If you think an invoice is wrong, please contact us within 14 days of receiving it and we will review it promptly.
Privacy: We use your billing information only to manage your account, in line with our privacy policy and Kenya’s Data Protection Act, 2019.
Ending this agreement: You or the centre may end this agreement by giving written notice. Fees for services already provided remain payable.

5. Declaration

Please tick each statement to confirm it.

6. Sign this form

Person responsible for payment: type your full name exactly as entered above.

Your full name as your signature *

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