NDIS Service Agreement Form

NDIS Service Agreement Form
Name*

Last Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Date of Birth*

DayMonthYear
Date
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Email: Support Coordinator/Plan Manager
example@example.com
This Agreement will start

DayMonthYear
Date
This Agreement will end with the plan end date*

Agree
Cross Care will be conducting your services as your intermediary's and or service provider*

Agree
Please Select your Services: (you can select more than one)

PhysiotherapyOccupational TherapySpeech PathologyPodiatryPsychologyBehaviour TherapyExercise PhysiologyHydrotherapyDietetics/NutritionHome Modification
NDIS Number - Starts with 43*
Where will the service take place?

In Home (Must be 20 minute radius from the clinic in Smithfield 2164 )In ClinicSchoolChild CareOther (Please Specify below)
Other (please specify)
When would you be requiring a report?

As soon as possibleWithin 3 weeksWithin 5 weeksJust before my plan end dateWithin 10 sessions
When is your plan end date?

MonthDayYear
Date
The terms and conditions outline that if you cancel within 48 hours (2 business days) of your session it will be billed and claimed for 100% of the NDIS charge. This is inline with the NDIS practice standards.*

Agree
If you wish to cancel due to school holidays and would like to keep your booking slot - you will be charged 80% of the NDIS session rate for every future booking canceled consecutively. this applies to all bookings that are weekly, fortnightly or monthly and cancel more than one consecutive session outside the 48 hour policy.*

Agree
Agreed Number of Sessions based on NDIS rates:*

Weekly SessionsFortnightlyOngoing
For Behaviour therapy ONLY

BSP Price Guidelines

IBSP (Interim Behaviour Support Plan to be completed if requested or within 28 days of RP identification)
5-6 hours for 1-2 RP
6-7 hours for 2+RP
* 1hr B for PRODA upload

FABSP (Comprehensive Behaviour Support Plan to be completed within 6 months of referral)
10-11 hours for 0-1RP
11-13 hours for 2 RP
13-15 hours for 3+ RP
*1hr B for PRODA upload

Progress Reports (to be completed 6-8 weeks before plan review)
2- 4 hours

Advocacy Letters (to be completed as needed)
1- 2 hours

BSP Review Reports (3,6,9,12 Monthly)
2- 4 hours

Intervention Action Plan (either quarterly or annually)
30 min - 1hr

Personalized Resources (for Intervention)
30 min - 2 hrs per clinician and program supervisor's discretion
Service Charge
prevnext( X )
Therapy Services/ReportsNDIS Price Guide*
$193.99AUD Number of Hours



Psychology Servises/ReportsNDIS Price Guide
$214.41AUD Number of Hours



Behaviour Therapy (CB Improved Relationships) Sessions/ReportWriting NDIS Price Guide
$222.99AUD Quantity



Total

$0.00AUD
COST Schedule of Supports (Breaks down what you are getting in terms of service)

Cross Care will follow the current NDIS price guide which can vary between $193.99 for Therapeutic Support or $214.41 For Psychology sessions, reports as well as Behaviour Therapy Reports

Travel rates are calculated on the above charges and are limited to 30 minutes. This is subject to change depending on updated price guides from year to year.

This will be applied and calculated based on the number of services received.

To find out more regarding the NDIS Price guide please follow the link provided:

https://www.ndis.gov.au/providers/pricing-arrangements#ndis-pricing-arrangements-and-price-limits
Participant understands that we will bill from their NDIS plan at the rate specified in the latest NDIS Support catalogue?*

I understand
The number of sessions required will depend on the therapists assessments/diagnosis and reports, and may change due to the clients needs throughout the duration of the plan:*

Agree
The session and travel rates are governed by the NDIS pricing guide. Travel charges depend on the location that the therapist is travelling from.*

I understand
Participant consent to creating a service booking?*

Agree
Cross Care - PARTICIPANT CONSENT DOCUMENT
EXCHANGE AND RECEIVE INFORMATION

Cross Care will keep your information private and confidential in a secure and safe place which will only be used by staff who support you and have permission to use it. The information that we exchange and receive will not be used for any other purpose other than assisting us in obtaining the appropriate help for you. I give permission for Cross Care to exchange and collect information on my behalf for accessing support, gaining assistance or advice and continuous improvement from other service providers, agencies and government departments. Some of these services may include:
EXCHANGE AND RECEIVE INFORMATION*

Carers/guardians/support peopleTreating health professionalsTravel agents or tour operatorsOther community and business servicesAuditorsDepartment of DisabilityNDIS Quality and Safeguard CommissionSchools and school teachersThere may be circumstances where your personal information may be shared with a third party for mandatory reporting purposes without consent being soughtAll the above
DUTY OF CARE I understand that I am required to adhere to the event hours and that Cross Care will not provide supervision outside of these times. I agree that I will not arrive more than 15 minutes prior to commencement and will leave no more than 15 minutes after completion of an event/session.

Agree
DUTY OF CARE I understand that the therapist will use the last 5-10 minutes of the session towards session notes. This helps therapists record progress after every session and goals targeted. It's generally used towards better quality for continuous therapy.

yes
DRUG AND ALCOHOL I understand that I am not permitted to be under the influence, consume, use or distribute alcohol and drugs whilst on the activities of Cross Care.

Agree
HEALTH AND SAFETY RULES

All persons at Cross Care including staff and participants have the responsibility to:
· Behave and act in a safe, pleasant and responsible manner whilst on all activities.
· Respect the rights, welfare and diversity of the group.
· Take care of any equipment and property.
· Report any hazards or safety issues and tell a staff member immediately.

· Inform AEP staff if you or any other person requires first Aid and report any injuries to staff.
I understand that I am required to adhere to the health and safety rules set out above.
HEALTH AND SAFETY RULES

Agree
Client's Signature or independent advocates signature

Clear
Name of Advocate/Guardian if signing on the Participants behalf:
Should be Empty:

NDIS Service Agreement Form

Cross Care - PARTICIPANT CONSENT DOCUMENT