2. INDIVIDUAL SERVICE AGREEMENT (PROF)

Individual Service Agreement - ISA (PROF)

Version 16.11.2021
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 Wonderland Community Services provides identification of requested agreed services provided by Wonderland Community Service Pty Ltd NDIS provider: 4050042146 ABN: 69627362912 trading as Wonderland Professionals and Pirates Professionals to the Participant for Capacity Building Supports.

The participant or participant's legal representative or delegated agreed representative (email or phone authorisation for delegate) provides authorisation for the following:

1. Service Delivery provided by Wonderland Community Services (Wonderland Professionals TAS) including: assessment, report provision, therapy and/or training and capacity building support services.

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

3. Permission to provide recommendations for restrictive practices in conjunction with nominated stakeholders where necessary where services required include Behaviour Supports.

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 (Wonderland Professionals) for the provision of Capacity Building Supports. This includes agreement to cancellation charges as identified in our Cancellation Policy detailed on our websites: www.wonderlandprofessionals.com.au

6. Authorisation of quarantining NDIS funds for service provision.

7. All prices are based on the NDIS Price Guide and are billed in accordance to the current price guide at the time of billing.

8. The continuation of service delivery (under this agreement) if the participants plan is extended.

Please note from 1 July Price Guide Changes - the following may be charged from participants funds.

Kilometre charges for fuel to travel to participants and return journey. (Where more than 1 participant is in an area - these costs are split) These will be charged at .85c per kilometre. In the case of remote travel - other travel charges will apply to participant funds. These will be negotiated prior to use and will necessarily reduce funds for face to face support.

Provider Travel Time - in non-face to face charges apply with the following line items.

Behaviour Support: 11_799_0110_7_3
Early Childhood Early Intervention: 15_799_0118_1_3
Therapy Suppports: 15_799_0128_1_3
Individual Social Skills Development: 11_799_0117_7_3 (travelling to the participant) or 11_590_0117_7_3 (for activity based transport).
Specialist Support Coordination Level 3: 07_799_0132_8_3

If you need help in completing this form, or need any translation/language support, please contact our service on: 0411 394 662
1. Participant Information
Name of Participant*

First NameLast Name
Date of Birth*

DayMonthYear
Date
Parent/Guardian's Name if applicable

First NameLast Name
NDIS Number*
Start of NDIS PLAN Date*

DayMonthYear
Date
End of NDIS PLAN Date*

DayMonthYear
Date
Participant's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Participant or Parent/Guardian's Phone
Participant or Parent/Guardian's Email
example@example.com
2. Care Planning Information
Disability, Medical and Health Related Information
Safety Considerations:
Please identify any safety issues for the participant or other people/community members that our staff should be aware of. Are there any locational safety issues for our staff in making home visits - for example animals, neighbours/co tenants/entrances etc.

Participant Goals

	Please identify the participants goals. Goals might be identified from the NDIS Plan
Goal 1
Goal 2
Goal 3
Goal 4

Are there any needs or preferences you would like to make us aware of before service provision commences (cultural/religious requirements, preference for age/gender of workers etc).
3. Participant Location
Approx. no of kms from Provider Site to Participant Location
Number of visits to Participant will vary
Participant's Location (Please select)*

(MMM 1-3) Metropolitan or Regional Centre - Major cities or regional locations within 15kms of towns with a population above 15,000 people (NAT)(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 (NAT)(MMM 6) Remote Area (MMM6) - further than 10 kms to a town up to 5,000 (REM)(MMM 7) Very Remote Area i.e. island location (VRA)
4. Service Request

Refer to participants location (MMM area) above to determine price charged. Note: there are sometimes differences between states and QLD - refers to Queensland, TAS - refers to Tasmania.
IMPROVED RELATIONSHIPS

0110 Behaviour Supports

	TOTAL FUNDS allocated for this service type	HOURLY FEE per LOCATION	TOTAL HOURS (divide funds by hourly fee)
A. (Assessment & Report) 11_022_0110_7_3
B. (Training) 11_023_0110_7_3
TOTAL

0117 Individual Social Skills Development

	TOTAL FUNDS allocated for this service type	HOURLY FEE per LOCATION	TOTAL HOURS (divide funds by hourly fee)
A. 11_024_0117_7_3
TOTAL

IMPROVED DAILY LIVING

0128 Therapeutic Support (QLD & TAS may need to be selected for some items). Note: If you are wanting to use your funding flexibly between our services, you can state the total amount of funding that you are willing to allocate.

	TOTAL FUNDS allocated for this service type	HOURLY FEE per LOCATION	TOTAL HOURS (divide funds by hourly fee)
A. COUNSELLING 15_043_0128_1_3
B. OCCUPATIONAL THERAPIST 15_617_0128_1_3
C. PSYCHOLOGIST 15_054_0128_1_3
D. SOCIAL WORKER 15_621_0128_1_3
E. THERAPY ASSISTANT LEVEL 2 15_053_0128_1_3
F. OTHER PROFESSIONAL 15_056_0128_1_3
TOTAL

I would like to use my Improved Daily Living funding flexibly between a therapist and therapy assistance (level2):

YesNo

0118 EARLY INTERVENTION SUPPORTS FOR EARLY CHILDHOOD (Please select Hourly fee item either QLD or TAS for Psychology Services)

	TOTAL FUNDS allocated for this service type	HOURLY FEE per LOCATION	TOTAL HOURS (divide funds by hourly fee)
A. COUNSELLOR 15_606_0118_1_3
B. OCCUPATIONAL THERAPIST 15_600_0118_1_3
C. PSYCHOLOGIST 15_001_0118_1_3
D. SOCIAL WORKER 15_603_0118_1_3
E. THERAPY ASSISTANT LEVEL 2 15_008_0118_1_3
F. OTHER PROFESSIONAL 15_005_0118_1_3
TOTAL

SUPPORT COORDINATION

0106 & 0132 Support Coordination

	TOTAL FUNDS allocated for this service type	HOURLY FEE per LOCATION	TOTAL HOURS (divide funds by hourly fee)
A. SUPPORT COORDINATION LEVEL 2 07_002_0106_8_3
B. SUPPORT COORDINATION LEVEL 3 07_004_0132_8_3

Psycho-social recovery coaches contains the following line items.

Psycho-social Recovery Coaches DESCRIPTION NAT MMM 1-5 REM MMM6 VRA MMM 7
A: 07_101_0106_6_3 Weekday - day $80.90 $113.26 $121.35
B: 07_102_0106_6_3 Weekday - evening $89.05 $124.67 $133.58
C:07_103_0106_6_3 Weekday Night $90.68 $126.95 $136.02
D: 07_104_0106_6_3 Saturday $113.49 $158.89 $170.24
E: 07_105_0106_6_3 Sunday $146.08 $204.51 $219.12
F:07_106_0106_6_3 Public Holiday $178.68 $250.15 $268.02
0106 Psycho-Social Recovery Coaches (Please select Hourly fee column either QLD or TAS)

TOTAL FUNDS allocated for this service type

TOTAL
INCREASED SOCIAL & COMMUNITY PARTICIPATION

	TOTAL FUNDS allocated for this service type
TOTAL

0117 Development of Daily Living and Life Skills

	TOTAL FUNDS allocated for this service type	HOURLY FEE per LOCATION	TOTAL HOURS (divide funds by hourly fee)
A. SKILLS DEVELOPMENT & TRAINING 09_009_0117_6_3
TOTAL

5. Funding Arrangements
Select how fees will be paid

NDIS portal direct withdrawalInvoice participant/guardianInvoice 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)
I authorise the quarantine of relevant nominated funds*

YesNoNot applicable (please provide invoice email address and phone number etc)
Name of Plan Manager or Self Managed Details
If applicable
Phone Number if applicable
Plan Manager or Self Managed Details (email)
example@example.com
Local Area Coordinator / Coordinator of Support

First NameLast Name
LAC/ COS Phone Number
LAC/ COS Email
example@example.com
Agency/Service Location
6. Additional Behaviour Support (permission)

Only applicable for participants requiring Behaviour Support Services.
Behaviour Support permission

By checking Yes and signing below, I agree for Wonderland Community Services NDIS authorised Behaviour Support Practitioners to provide behaviour support assessment, devise a report and understand that this might include Regulated Restrictive Practice/s. I understand that I will be consulted along this process and that there will be regular reviews to ensure my rights as a person are upheld and that I am safe.
Agreement required for Behaviour Support Services to be actioned (participant or delegate)

YesNo
Positive Behaviour Support Plans are designed to reduce any need for 'restrictive practices' which limit a person's freedom.

A Positive Behaviour Support Plan seeks to find out ways to reduce stress for a person through changing things in their environment. It might mean helping with communication, training staff and/or looking at any needs that are not being met for that person. All behaviour serves a purpose - finding out what need the behaviour is serving is the first step to resolving behaviours of concern.

Disabilities can sometimes make communication difficult and this can cause frustration. A Positive Behaviour Support Plan is designed to assist everyone concerned to respect the needs, preferences and interests of the person with a disability by finding alternate ways to meet their needs so that they don't have to resort to behaviours which may harm them or others or property.

At times, there may be a need to implement a 'regulated restrictive practice' to ensure that the person with a disability is safe and that the people around them are safe.

These restrictive practices will only be used for the shortest time possible and are not designed to frustrate or injure the person with a disability.

All regulated restrictive practices (which need to go through an authorisation period with the NDIS Commission and with consultation with all stakeholders) will be clearly listed in the Positive Behaviour Support Plan and will contain clear information on the limited uses of these practices as well as strategies for reducing the need for these practices over time.

Regulated Restrictive Practices might include:

Mechanical restraints - like car harnesses so that drivers and passengers are safe in a car journey.
Chemical restraints - like medications that might be used 'on a needs basis' for calming someone when they are extremely distressed.
Physical restraints - like holding someone back from running onto a busy road or holding someone so that they stop injuring themselves or another person.
Seclusion - not allowing someone to exit a room for a time so that safety for them and others is assured. This might be until police or ambulance arrive for example.
Environmental restraint - which means limiting access to parts of a person's environment which may pose a threat to them or someone else - this might include putting away knives, or foods that might cause harm.
7. Signatures

The following signatures provide both agreement for this service provision as well as authorisation for obtaining and releasing information for the participant to assist in this service provision.
Participant/Guardian or Delegate

First NameLast Name
Authorised person's email
example@example.com
Date

DayMonthYear
Date
Signature of Participant or authorised representative
Service Provider Signature
SERVICE PROVIDER Representative Name

First NameLast Name
SERVICE PROVIDER Representative Email
example@example.com
SERVICE PROVIDER Representative Signature

Clear
Date

DayMonthYear
Date
Send ISA to:
Should be Empty:

Individual Service Agreement - ISA (PROF)

1. Participant Information

2. Care Planning Information

3. Participant Location

4. Service Request

5. Funding Arrangements

6. Additional Behaviour Support (permission)

7. Signatures

Service Provider Signature