Form 5 Counselling and Report Fee Invoice

Form 5 - Counselling and Report Fee Invoice

Section 1: Applicant Details

Applicant name: *

First

Last

Applicant’s address:

Address Line 1

Address Line 2

City

State

Zip Code

Tribunal reference number:

Tribunal venue:

Section 2: Counsellor / Report Writer Details

Name of report writer/counsellor: *

First

Last

Name of business / agency:

ABN of business / agency:

Postal/payment address of business / agency:

Address Line 1

Address Line 2

City

State

Zip Code

Counsellor reference:

Bank/Name/BSB

Section 3: Counselling Fees Claimed

Date of counselling session *

Duration of session (Hr: Min)

Date signed: *

Fee Claimed

Date of counselling session *

Duration of session (Hr: Min)

Date signed: *

Fee Claimed

Date of counselling session *

Duration of session (Hr: Min)

Date signed: *

Fee Claimed

Date of counselling session *

Duration of session (Hr: Min)

Date signed: *

Fee Claimed

Date of counselling session *

Duration of session (Hr: Min)

Date signed: *

Fee Claimed

Date of counselling session *

Duration of session (Hr: Min)

Date signed: *

Fee Claimed

Section 4: Report Fee Claimed

Report Description (e.g., date of report, report type, time spent preparing report)

Fee Claimed

Section 5: Counsellor / Report Writer Certification

Name *

First

Last

certify that: (name of person that authored the report / provided counselling to applicant) I wrote and signed the report referred to in this invoice (delete clause if no report filed with invoice). The counselling session(s) claimed in this invoice was (tick box for relevant clause): - previously authorised by the Tribunal by - not previously authorised by the Tribunal.

letter/notice dated

The counselling sessions detailed in this invoice were provided by me (delete clause if no counselling claimed in invoice). I signed this invoice in the column headed ‘signature of counsellor’ at the conclusion of each counselling session claimed in this invoice (delete clause if no counselling claimed in invoice). The applicant signed this invoice in the column headed ‘signature of applicant’ at the conclusion of each counselling session claimed in this invoice (delete clause if no counselling claimed in invoice). I understand that the filing of this invoice does not guarantee payment of all or part of the amount claimed, and that the amount awarded for expenses is at the discretion of the Tribunal.

Counsellor’s Occupation

Dated

We are committed to elevating both organisational and personal health and well-being, with focus on enhancing performance and productivity.

Form 5 Counselling and Report Fee Invoice