NDIS Service Agreement Form
Cross Care
Name
*
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Date of Birth
*
/
Day
/
Month
Year
Date
Address
*
Street Address
Street Address Line 2
City
State
Zip Code
Email: Support Coordinator/Plan Manager
example@example.com
This Agreement will start
-
Day
-
Month
Year
Date
Back
Next
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:
Physiotherapy
Occupational Therapy
Speech Pathology
Podiatry
Psychology
Exercise Physiology
Hydrotherapy
Dietetics/Nutrition
Home Modification
Where will the service take place?
In Home (Must be 20 minute radius from the clinic)
In Clinic
School
Child Care
Other (Please Specify below)
Other (please specify)
Agreed Number of Sessions based on NDIS rates:
*
1-5 Sessions
5-10 Sessions
Weekly Sessions
Fortnightly
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
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Signature
*
Clear
Name of Advocate/Guardian if signing on the Participants behalf:
Submit
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