Service Agreement Form
The Shepherd Speech Room
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
This Agreement will end with the plan end date
*
Agree
The Shepherd Speech will be conducting your services as your intermediary's and or service provider
*
Agree
Please Select your Services:
Speech Pathology
Speech Pathology Assistant
Behavioural Therapy
NDIS Number - Starts with 43
*
Where will the service take place?
In Home (Must be 30 minute radius from the Therapist base - The ponds 2769 64 )
In Clinic
School
Child Care
Other (Please Specify below)
Other (please specify)
When would you be requiring a report?
As soon as possible
Within 3 weeks
Within 5 weeks
Just before my plan end date
Within 10 sessions
When is your plan end date?
-
Month
-
Day
Year
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 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.
*
Agree
Agreed Number of Sessions based on NDIS rates:
*
Weekly Sessions
Fortnightly
Ongoing
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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