APPLICATION FOR ARBITRATION OF AN ACCOUNT
I, the undersigned, ___________(client’s name)___________ ___________(address)___________ declare that:
(1) ___________(social worker’s name)___________ is claiming from me (or refuses to reimburse to me) a sum of money for professional services.
(2) I have enclosed a copy of the conciliation report.
(3) I am applying for arbitration of the account under the Regulation respecting the conciliation and arbitration procedure for the accounts of members of the Ordre professionnel des travailleurs sociaux et des thérapeutes conjugaux et familiaux du Québec (chapter C-26, r. 294).
(4) I have received a copy of the Regulation mentioned above and have taken cognizance thereof.
(5) I agree to submit to the procedure provided for in that Regulation and, where required, to pay to ___________(social worker’s name)___________ the amount of the arbitration award.