School/center Retainer Agreement Template Page 2

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The observations and recognized assessments we do at The Ollena Center are designed to identify a
possible developmental delay or learning disability. We do not make any diagnoses. We provide the
school and parents with accurate information and assessment data while we help the school and the
students’ families identify community resources that can make a professional diagnosis and/or start a
therapy plan for a student, if needed.
 The Ollena Center for Early Child Assessment, LLC also offers a limited service one month
plan designed with your specific needs in mind. Upon request.
By signing this agreement, I agree to retain The Ollena Center for Early Childhood
.
Assessment, LLC as per the services, conditions and fees listed
Choose a payment option:
____ (initial) one time payment of $12,000. on/before __________________ for the school year 2015-
2016.
_____(initial) two payments of $6,000. each, first payment on__________________, second payment
January 5, 2016 for the school year 2015-2016.
_____(initial) monthly payments of $1,500. on the first of each month, September through April, for the
school year 2015-2016.
_____(one month) one payment of $1,500. on or before the first date of service.
Checks can be mailed to 3162 Johnson Ferry Road Ste 260-111, Marietta, GA 30062 or delivered in
person.
Date_____________________________
Name of person signing____________________________________________________
Position ________________________________________________________________
Phone____________________________________________
Email_____________________________________________
Signature______________________________________________________________
Signature________________________________________________ (Donna T. Anello)
2
School/Center Retainer Form | The Ollena Center LLC.

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