Third Party Payment 


When a Third Party such as a parent, family member, partner, employer or other benefactor agrees to pay for treatment, this form obtains guarantor details and your client’s permission to communicate with them regarding billing.

When a third party, such as a parent or employer, offers to cover a client’s therapy costs, this document obtains the client’s permission to share relevant information with them, including:

  • Description of Services
  • Date and location of services
  • Attendance
  • Payment Process

It clarifies for the client what information will not be shared to reassure them of their privacy.

We have also included a template for a letter to send to guarantor’s explaining privacy boundaries and letting them know what to expect from you in terms of payment and non-payment processes.

Having an agreement means that everyone is clear on privacy and payment processes, on responsibility for payment and repercussions in the event of non-payment.


This document is

  • Customisable and editable
  • Reviewed by lawyers 2020
  • Format updated September 2021

This document is not

  • is not a sliding scale agreement
  • is not a Release of Information
  • is not a Health Insurance Reimbursement form

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