INDIVIDUAL SERVICE AGREEMENT (ISA) WCS

INDIVIDUAL SERVICE AGREEMENT (ISA) WCS

For Wonderland Retreat and Associated Services TASMANIA and Pirates Rest and Associated Services QUEENSLAND
If you need help in completing this form, or need any translation/language support, please contact our service on:TAS 0499 796 661 or QLD 0413 462 840
This Service Agreement is made for the purpose of providing supports under the participant’s NDIS plan.

The parties agree that this Service Agreement is made in the context of the NDIS, which is a scheme that aims to:

· support the independence and social and economic participation of people with disability, and

· enable people with a disability to exercise choice and control in the pursuit of their goals and the planning and delivery of their supports

This agreement between the NDIS Participant and/or their Guardian or Delegate and Wonderland Community Services provides identification of requested agreed services provided by Wonderland Community Service Pty Ltd NDIS provider: 4050042146 ABN: 69627362912 trading as Wonderland Retreat/Wonderland Hideaway/Wonderland Care/Wonderland Adventures/Wonderland Day Program to the Participant for Core Supports.

The participant or participant's legal representative or delegated agreed representative (delegation can occur through the an attached email or phone authorisation for delegate) provides authorisation for the following activities:

1. Service Delivery provided by Wonderland Community Services for Short Term Accommodation/Respite and Medium Term Accommodation and associated supports including In-home care and Social, Community & Recreational Activities and Group Centre Activities.

2. Authorisation to contact agreed support and network personel as detailed below to enable a quality service delivery to the participant and to communicate with them as necessary the appropriate information contained in this agreement.

3. Identification of safety issues for the participant and for service provision.

4. Provision of Care Planning information regarding goals, needs, preferences for the participant in order to provide quality services.

5. Identification of finances made available to Wonderland Community Services Pty Ltd for the provision of Core Supports. This includes agreement for cancellation charges as identified within our cancellation policy document and the NDIS Price Guide recommendations. Authorisation of quarantining NDIS funds for service provision. Charging pro-rata time rates for transport for STA - 4% for trips up to 30 mins, 7% for trips up to 60 mins and 9% for trips up to 90 mins per day. Where no transport budget is identified fees may be charged at .85c per kilometre from other available funds.

6. Permission to implement recommendations for restrictive practices in conjunction with nominated stakeholders where necessary and where services required include Behaviour Supports for the participant under the guidance of the nominated Behaviour Support Practitioner.

7. Understanding of the limits of this agreement.
Location of service
Site
Service Agreement

CARE PLANNING
Service Agreement Start Date *

Day Month Year
Date
Service Agreement End Date *

Day Month Year
Date
Participant Details
Name of Participant *

First Name Last Name
Date of Birth *

Day Month Year
Date
Age at the start of this agreement
NDIS Number *
Start of NDIS PLAN Date *

Day Month Year
Date
End of NDIS PLAN Date *

Day Month Year
Date
Participant's Current Address *

Street Address

Street Address Line 2

City State

Post Code
Participant's Location

(MMM 1-3) Metropolitan or Regional Centre - Major cities or regional locations within 15kms of towns with a population above 15,000 people. (MMM 4-5) Regional Area (MMM 4-5) - Inner regional or outer regional within 10 kms to a town up 5,000-15,000 population (MMM 6) Remote Area (MMM6) - further than 10 kms to a town up to 5,000 (MMM 7) Very Remote Area i.e. island location
Approx. no of kms from Provider's Address to Participant Location *
This information is required for any travel/transport required for the participant including pick ups and drop offs for the participant.
Disability Information
Disability Information/Diagnosis *

Physical Disability Intellectual Disability Developmental Disorder (ASD/ADHD) Mental Health Disability including Attachment Disorder/PTSD/ODD/RAD
Other Disability Information *
Please provide as much detailed information as possible so that we are aware and can ensure safety for the participant.
Agreed Ratio of Support for Accommodation Services (based on risk assessment)

1:4 (1 support worker to 4 participants) 1:3 (1 support worker to 3 participants) 1:2 (1 support worker to 2 participants) 1:1 (1 support worker to 1 participant) 2:1 (2 support workers to 1 participant)
1. Service Requested
Indicate Funding Stream for this Service Agreement *

0115 Short Term Supported Accommodation and Respite - weekend or up to 2 weeks support 0115 Short Term Supported Accommodation/ Day Program - negotiated if the full 24 hrs is not required 0115 Medium Term Accommodation MTA (please also add 0104 and/ or 0125 below) 0115 Supported Independent Living (SIL) 0104 & 0107 Assistance with Self Care Activities 0125 Assistance to Access Community, Social and Recreational Activities 0104 & 0107 Establishment Fee - new participant 0125 Establishment Fee - new participant
As part of the service we would appreciate assistance with the following for the participant *

Assistance with improved self care/independence Assistance with relationship building/social skills Assistance with mental health/emotional safety Assistance with preparation for the workforce Assistance for preparation for household management Assistance with building self esteem and self knowledge Assistance in accessing relevant community activities in line with interests
2. Agreed Support Network Contact Details
OBTAIN AND RELEASE INFORMATION PERMISSION

By signing this form, I agree that the following people may be contacted to assist in supporting this service. I also agree that these people may have access to the information provided through the provision of this service.

Please note if at any time you would like to withdraw permission for any or all of these contacts - please let us know via our website or via your Support Coordinator.
Key Contact *

Participant Parent Guardian
Key Contact name *

First Name Last Name
Key Contact Number *
Email *
example@example.com
Support Coordinator Name

First Name Last Name
Support Coordinator Phone
Support Coordinator Email
example@example.com
Another person who can be contacted as an emergency contact for the participant. *

Carer Professional Coordinator of Support Family Member
Name of emergency contact *

First Name Last Name
Emergency contact number *
Agency if applicable
The following people are able to be called to provide up to date medical/medication information for the participant.
Doctor Contact Details *
Include name, phone, email and practice name/location.
Pharmacist Contact Details
Please include name, phone, email and practice/name location.
Pediatrician/Psychiatrist and Contact Details (if applicable)
Please include name, phone, email and practice name/location.
3. Finance Provision for Services

Fees for Services - please identify service provision and complete table as required.
0115 Short Term Supported Accommodation & Assistance including Respite (STA)

Daily Fees - typically 1 to 14 days
The following fees are charged on a pro-rata basis for support in Short Term Accommodation & Assistance and Respite Care - typically broken into the following periods.
- Friday 4 pm to Friday midnight: 20%
- Friday midnight to Saturday to 4 pm: 80%
- Additional time is charged on a pro-rata basis for pick-ups and drop-offs for worker time. 4 % of the daily rate per journey for up to 30 mins/30 kms, 7% per journey for up to 60 mins/60 kms, 9% per journey up to 90 mins/90 kms.
- These rates also apply to short notice cancellations which are less than 5 full days notice period.

DAY (24 hr charge)	1:4 Support Fee	1:3 Support Fee	1:2 Support Fee	1:1 Support Fee
Weekday	$626.62	$771.24	$1,060.48	$1,928.20
Saturday	$761.02	$950.44	$1,329.28	$2,465.80
Sunday	$925.60	$1,169.88	$1,658.44	$3,124.12
Public Holiday	$1,090.18	$1,389.32	$1,987.60	$3,782.44

Additional care for participants requiring 1:1 support at different times during STA will use the price guide below. - Non-face to face support outside of the hours for the participant using STA services will also incur costs at the hourly rate below and may be utilised for incident report follow ups, communication for the participant's wellbeing with guardians, COS, emergency services and other stakeholders.

0115 Medium Term Accommodation - 2 weeks - 12 weeks (MTA)
This support item covers the accommodation costs of Medium Term Accommodation (MTA). The support component of the care is to be charged separately. Typically, MTA would be used for periods up to 90 days. Participants who stay in MTA are responsible for meeting their own food and everyday living costs from their own income rather than NDIS plan.

As well as direct service provision, this support item can be used to claim for
Short Notice Cancellations.

Please note: Wonderland Community Services is unable to provide Medium Term Accommodation without also providing usual care support during the period of Medium Term Accommodation. This may mean releasing funds from other providers during this period to adequately support the participant during this time. Please review Assistance with Self Care and Assistance to Access Community, Social and Recreational Activities. Our tenancy agreements require 24/7 supervision of the property and adequate support and supervison of medium-term tenants.

0107 Assistance with Self Care Activities and 0125 Assistance to Access Community, Social and Recreational Activities

HOURLY RATE	Weekday (during the day)	Weekday (evening)	Weekday (night)	Saturday	Sunday	Public Holiday
MMM1-5	$62.17	$68.50	$69.77	$87.51	$112.85	$138.20

As well as direct service provision, these support items can be used to claim for:
* Non-Face-to-Face Support Provision
* Provider Travel
* Short Notice Cancellations
* NDIA Requested Reports
Providers of these supports can also claim for the costs of:

* Provider Travel - Non-Labour Costs using the support item 01_799_0107_1_1

Establishment fee for Personal Care and Soc, Ec, & CommParticipation	MMM1-5
01_049_0107_1_1	$621.70

0115 Supported Independent Living (SIL)

HOURLY RATE (Standard)	Weekday (during the day)	Weekday (evening)	Weekday (night)	Saturday	Sunday	Public Holiday	Sleep Over (9pm -7am)
National	$62.17	$68.50	$69.77	$87.51	$112.85	$138.20	$262.16
Remote	$87.04	$95.90	$97.68	$122.51	$157.99	$193.48	$367.02
Very Remote	$93.26	$102.75	$104.66	$131.27	$169.28	$207.30	$393.24

HOURLY RATE (High Intensity)	Weekday (during the day)	Weekday (evening)	Weekday (night)	Saturday	Sunday	Public Holiday	Sleep Over (9pm -7am)
National	$67.28	$74.14	$75.51	$94.71	$122.14	$149.57	$262.16
Remote	$94.19	$103.80	$105.71	$132.59	$171.00	$209.40	$367.02
Very Remote	$100.92	$111.21	$113.27	$142.07	$183.21	$224.36	$393.24

As well as direct service provision, these support items can be used to claim for:
* Non-Face-to-Face Support Provision
* Provider Travel
* Short Notice Cancellations
* NDIA Requested Reports

Providers of these supports can also claim for the costs of:
* Provider Travel - Non-Labour Costs using the support item 01_799_0104_6_1
* Activity-Based Transport - Social, Economic and Community Participation Supports using support item 04_592_0104_6_1
* Centre Capital Costs using support item 04_599_0136_6_1, when the support is provided in a centre rather than in the community

* Non-Face to Face supports will be charged through the appropriate line items and may be utilised for additional services for participant capacity building and wellbeing including incident report follow-ups, end of plan plan reports, team communications and meetings with external stakeholders, meetings with health and allied health services.

Please note - (Wonderland Community Services - and service divisions) fees will change as per NDIS Price Guides released periodically - the fees quoted above provide a guide only. Any existing agreements signed will have an automatic price rise in line with changes in the Price Guide. Please note when Price Guide changes occur - participant plan income is automatically increased by NDIS to accommodate these changes. Where price quotes are in place for multi-disciplinary teamwork this quote is valid until the end of the participant's plan. Please send through a Roster of Care to wcsadmin@wonderlandcommunityservices.com.au to assist us in providing a quote.
4. Funding arrangements
Total Funds or Hours Authorised for Service Delivery *
Select how fees will be paid *

NDIS direct withdrawal Invoice participant/guardian Invoice plan manager
Where fees are directly withdrawn from NDIS portal the participant/participant's representative authorises quaranting of funds for this service delivery.

Wonderland Community Services warrants that it will release funds speedily should the participant/participant's guardian request this. (within 3 buisness days)
If NDIS through the portal paid - I authorise the quarantine of relevant nominated funds *

Yes No Not applicable (please provide invoice email address and phone number etc)
If not claiming through NDIS directly - Name of Plan Manager or Self Managed Details
(Name of person responsible)
Phone Number (if applicable)

Area Code Phone Number
Email of Plan Manager or Self Managed Details
example@example.com
1. I warrant that I have read THIS information below regarding the responsibilities for the Provider and the Participant (or representative) and agree to uphold these requirements.

2. I understand that cancellation and non-face to face fees may apply and I have read the Providers Cancellation Policy on the Providers website (www.wonderlandretreat.com.au/www.piratesrest.com.au/ https://wonderlandcommunityservices.com.au/) and agree to abide by this policy.

3. I understand that I have the right to alter this agreement - and will negotiate and provide desired changes to the agreement in writing to the Provider. Unless otherwise notified of changes by either party, review of this agreement will be every 11 months.

4. I understand that I have the right to complain and dispute service provision and have read the Complaints Policy on the Providers website (www.wonderlandretreat.com.au/www.piratesrest.com.au) so that I know what to do in the event that I am not happy with this service provision.

5. I agree to have an establishment fee charged if I am registering a new participant to Wonderland (0104 or 0107 or 0125)

6. I am happy for an hourly fee (3 hrs) to be added to claims for a report that I require (participant or nominee) for NDIS plan reviews (0115, 0104, 0107 or 0125)

7. I am willing to discuss any issues I may have with the services provided with the Team Leader/ Manager of the service.

8. In the event that the service provided does not suit the needs of the Participant, the Provider agrees to release and cancel the agreement with 14 days' notice in writing from the Participant or Delegate. Services planned and rendered will be billed up to and including the last day of service. It is the intention of this agreement that both parties will work collaboratively to ensure the needs of the Participant are met and work through any unforeseen issues for the best interests of the Participant.

9. I agree to the implementation of restrictive practices by the service provider with the authorised permissions and plans for a PBSP is in place.

10. I recognise and agree to the limits of this agreement including:

* the Provider will be released from providing services (withdrawing service) if the Provider accommodation and other resources are not sufficient to support the participant typically under the following conditions:

* if no further funds are available to provide this service - I understand that my Coordinator of Support or Guardian will arrange other services until such times as funds are provided

* use of illicit drugs or alcohol leading to intoxication on the property (which may impact the wellbeing of other participants)

* unreasonable disregard for the rules of Wonderland Community Services including abusive language towards staff or participants and or unwillingness to respond to direction provided by caregivers or senior staff in order to manage the ongoing safety and protection of all participants

* violent or aggressive behaviour towards staff, participants or community members (which may impact the wellbeing of other participants)

* absconding from the nominated premises where the services are provided so that safety is compromised and can't be assured

* destruction of property or hazardous behaviour which could lead to the destruction of property and a compromise of safety for self or others
5. Signatures

I have read the above information and have specified my agreements to the applicable sections above. I am happy to proceed with this service delivery.
Date

Day Month Year
Date
Participant/Parent/Guardian Name *

First Name Last Name
Relationship to Participant *
Participant/Parent/Guardian Email *
example@example.com
Signature of Participant/Participant's Guardian or Participant's Nominated Delegate.
Wonderland's Representative's Name

First Name Last Name
Wonderland Email
example@example.com
Date

Day Month Year
Date
Wonderland Community Services Authorised Representative Signature
Send ISA to: *
Version: 10/02/2022
Should be Empty:

Fees per day	Accommodation Only
MMM1-5	$137.15
MMM6	$192.01
MMM7	$205.73

HOURLY RATE	Weekday (during the day)	Weekday (evening)	Weekday (night)	Saturday	Sunday	Public Holiday
MMM1-5	$62.17	$68.50	$69.77	$87.51	$112.85	$138.20

INDIVIDUAL SERVICE AGREEMENT (ISA) WCS

Service Agreement

Participant Details

Disability Information

1. Service Requested

2. Agreed Support Network Contact Details

3. Finance Provision for Services

0115 Short Term Supported Accommodation & Assistance including Respite (STA)

0115 Medium Term Accommodation - 2 weeks - 12 weeks (MTA)

0107 Assistance with Self Care Activities and 0125 Assistance to Access Community, Social and Recreational Activities

0115 Supported Independent Living (SIL)

4. Funding arrangements

5. Signatures