Participant Services Agreement - KoalaKare

Participant Services Agreement

Step 1 of 6
Client Name

First NameLast Name
Email
example@example.com
Clients Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Commencement Date

DayMonthYear
Client’s Representative (if applicable)
Is the Plan NDIA Managed (if applicable)
Registered Plan Management Provider (if applicable)
Plan Manager Email
Plan Manager Phone Number

Area CodePhone Number

Participant Services Agreement

Schedule 2 – The Services - Step 2 of 6
What services will be provided
How will the services be provided

Social Media Photo, Interview and Video Release Form

Step 4 of 6
Can we use your name?
Nickname
Terms and conditions

Monies and Property Consent Form

Step 5 of 6
Provider Declaration
We are committed to:
- ensuring that clients are supported to manage, control, access and spend their own money as they determine.
- ensuring that where staff have access to a client’s money or other property, that it is managed, protected and accounted for.
- exercising a duty of care to ensure that clients funds are not exploited or disadvantaged.
- ensuring that clients’ money or other property will only be used with the consent of the client and for the purposes intended for the client.
We encourage you to manage your own funds wherever possible.

We will not provide financial information, advice or information other that which would reasonably be required under your plan.

We will not informally manage your funds without your explicit consent. We will not make decisions regarding your funds without your consent and guidance.

Our systems will include appropriate checks and balances to ensure the safeguarding of clients from being exploited, and to protect staff from allegations of financial mismanagement.

This consent does not relate to the provision of Plan Management services.
Client Declaration
I acknowledge that KoalaKare has advised me of the following:
- KoalaKare’ Handling Client Monies Policy and Procedure;
- my right to access my personal property and monies;
- my right to lead decision-making around how I spend my money;
- my right to withdraw my consent at any time.
Client Consent
I give consent for KoalaKare to handle my personal property and monies in the following ways
Property / amount of money to be managed
How is it to be managed
The end date for consent

DayMonthYear
Date
Where the property / money is to be kept
Any further details

Participant Services Agreement

SIGNED AS AN AGREEMENT - Step 6 of 6
KoalaKare Pty Ltd (ACN 66 663 742 498)
TOTAL PAYABLE AMOUNT: ( WEEKLY ) {grandTotal106}

** Please note that this service agreement excludes costs for services provided on public holidays
Name of person signing

First NameLast Name
Signature
Date

DayMonthYear
Representative
For or on behalf of the Client
Name of person signing --- Capacity of person signing (i.e Client / Client’s Representative)

First NameLast Name
Signature
Date

DayMonthYear
Should be Empty: