The Shepherd Speech Room Service Agreement Form

Service Agreement Form

The Shepherd Speech Room
Name

Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
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
The Shepherd Speech will be conducting your services as your intermediary's and or service provider
Please Select your Services:
NDIS Number - Starts with 43
Where will the service take place?
Other (please specify)
When would you be requiring a report?
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.
If you are booked for ongoing/repeated sessions ie. weekly, fortnightly or monthly and cancel more than one consecutive session and wish to keep your booking time - you will be charged 50% of the NDIS session rate for every future booking canceled consecutively.
Agreed Number of Sessions based on NDIS rates:
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:
The session and travel rates are governed by the NDIS pricing guide. Travel charges depend on the location that the therapist is travelling from.
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Signature
Name of Advocate/Guardian if signing on the Participants behalf:
Should be Empty:

Service Agreement Form

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