Service Change Request Form

Service Change Request Form

Applicable for 1:1 Services
Personal Details
Child's Full Name*
As per NRIC / Passport
Requestor's Full Name*
As per NRIC / Passport
Relationship to Child*
Email Address*
Type of Service Request
I would like to request for my current service to be the following:*
Details of Service Request
Fill in this section if you are requesting to update the therapy or supervision hours. Leave blank if not applicable.

NEW ADDRESS

Fill in this section only if you are requesting to change the address for where services shall be delivered. Please be notified that new travel charges may apply based on the new address.
New Address
Effective Start Date of Change*

DayMonthYear
Date
End Date*

DayMonthYear
Date
Terms and Conditions
Today's Date

MonthDayYear
Please thoroughly read and understand the below Terms and Conditions prior to submission.
1. One (1) month's written notice is required for changes in the 1:1 ABA Program model, other than the Consultation (Supervision) Only model.
2. Two (2) months' written notice is required for change of service to the Consultation (Supervision) Only model.
3. Freezing of Program as per Service Agreement.
By submitting this form, you, the Parent or Guardian of the above child

: agree to abide by the notice period required for the request in change of service as described in this form

: agree that in the event this form is submitted without sufficient notice period, SEED has the rights to reject the request

: understand that there shall be changes in fees, corresponding to the service change

: understand that this request shall adhere to the terms and conditions laid out in the Service Agreement and its addendum (if any) that follows.
Should be Empty:

	Home	Centre
Therapy hours per WEEK
Supervision hours per MONTH