INDIVIDUAL SERVICE AGREEMENT (ISA)

INDIVIDUAL SERVICE AGREEMENT (ISA)

This ISA pertains to 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

Please see notes at end of this form for more information about this agreement. ISA (Individual Service Agreement)
Location of service
Site
Service Agreement

CARE PLANNING
Service Agreement Start Date*

DayMonthYear
Date
Service Agreement End Date*

DayMonthYear
Date
Participant Details
Name of Participant*

First NameLast Name
Date of Birth*

DayMonthYear
Date
Age at the start of this agreement
NDIS Number*
Start of NDIS PLAN Date*

DayMonthYear
Date
End of NDIS PLAN Date*

DayMonthYear
Date
Participant's Current Address*

Street Address

Street Address Line 2

CityState

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
Disability Information
Disability Information/Diagnosis

Physical DisabilityIntellectual DisabilityDevelopmental Disorder (ASD/ADHD)Mental Health Disability including Attachment Disorder/PTSD/ODD/RADOther
Other Disability Information*
Please provide as much detailed information as possible so that we are aware and can ensure safety for the participant - further information can be provided via the Service Request Form.
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/s Requested
Indicate Funding Stream for this Service Agreement*

0115 Short Term Supported Accommodation and Respite (including Day Program) - weekend or up to 2 weeks support0115 Medium Term Accommodation MTA (please also add 0104 and/ or 0125 below)0115 Supported Independent Living (SIL)0104 or 0107 Assistance with Self Care Activities0125 Assistance to Access Community, Social and Recreational Activities plus Community, Social and Recreational Activities & Community Participation Activities (Wonderland and Pirates Club)0106 Life Transition Planning
As part of the service we would appreciate assistance with the following for the participant*

Assistance with improved self care/independence/emotional regulationAssistance with relationship building/social skillsAssistance with mental health/emotional safetyAssistance with preparation for the workforceAssistance for preparation for household managementAssistance with building self esteem and self knowledgeAssistance in accessing relevant community activities in line with interestsDevelopment of a Care Plan and Specific ActivitiesDevelopment of an Emergency and Disaster Management strategy for your participant while in our careSupport for English as a second language/interpreter support
Please note that WCS will provide a care plan for the participant which can be requested at any time.

Emergency and disaster provisions will be made for participant's support. Please refer to our policy on our website. This is also individualised in the participant's care plan after signing this agreement.
Please provide your authority to allow our staff to administer medication to the participant.
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*

ParticipantParentGuardianSupport Coordinator
Key Contact name*

First NameLast Name
Key Contact Number*
Email*
example@example.com
Another person who can be contacted as an emergency contact for the participant.*

CarerProfessionalCoordinator of SupportFamily Member
Name of emergency contact*

First NameLast 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. Funding arrangements

Fees for Services - please identify service provision and complete table as required. Please note when the PRICE GUIDE changes WCS will charge the new updated prices as per the guide.
Please note - (Wonderland Community Services - and service divisions) fees will change as per NDIS Price Guides released periodically. Please review website for changes. 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.
Please click on the links below to our websites for up-to-date price information for the related line item for services that you require.

FOR PIRATES REST QUEENSLAND

https://piratesrest.com.au/fees/

FOR WONDERLAND RETREAT TASMANIA

https://wonderlandretreat.com.au/fees/
Below you will find boxes where total allocated for specific services or for flexible use of CORE funds can be provided. At times participants may choose to use CAPACITY funds flexibly as well.

This information will allow for simple service bookings to occur for the participant. Please note non face to face-to-face services and km/travel will be charged out of these total funds allocated on the nominated line items. Where items are not applicable please write N/A.
FLEXIBLE FUNDING
Total Funds Available for CORE SUPPORTS TO BE USED FLEXIBLY*
This might be expressed as for example 9 hours per week.
Total Funds Available for CAPACITY BUILDING SUPPORTS TO BE USED FLEXIBLY*
This might be expressed as for example 9 hours per week.
SPECIFIED FUNDING
Total Funds Authorised for Service Delivery for Accommodation Services 0115 *
Please identify total funds allocated to WCS for this service. this includes: SHORT TERM ACCOMMODATION/RESPITE, MEDIUM TERM ACCOMMODATION, SUPPORTED INDEPENDENT LIVING, INDIVIDUALISED LIVING OPTIONS - DAY PROGRAMS with ACCOMMODATION
Total Funds or Hours Authorised for Service Delivery for Care Services delivered in the home 0107 or 0104*
This might be expressed as 20 hrs per week for example.
Total Funds or Hours Authorised for Service Delivery for Care Services delivered in the community 0125 - this option may be delivered as a course offered by the organisation. *
This might be expressed as for example 9 hours per week.
Courses we Offer

Horticulture and Animal Care Course ($15 per week)Food Lovers Course ($25 per week)Outdoor Sports and Recreation Course ($35 per week)Arts and Crafts Course ($20 per week)
Please select this option, if any of the above courses is selected

Claim course fee weekly
Total Funds or Hours Authorised for Service Delivery for Care Services delivered in the community 0116, 0117, 0106, 0136 - these options may be delivered as a course offered by the organisation.*
This might be expressed as for example 9 hours per week.
Total Funds or Hours Authorised for Service Delivery for Early Childhood under 0118*
This might be expressed as for example 9 hours per week.
Total Funds authorised for use of Transport Budget*
Please state 0 if no allowance provided.
Other Special Arrangements
Wonderland Community Services (Wonderland Retreat and Pirates Rest) would appreciate specific funding being identified for our organisation if at all possible - this is to ensure seamless delivery of services going forward.
Degree to which participant is dependent on Wonderland Community Services

LEVEL 5 - Completely dependent ( 14-24hrs care per day - 52 weeks per yr) and needs meds supervisionLEVEL 4 - Mostly dependent (10-14 hrs per day) 52 weeks per yr) and needs meds supervisionLEVEL 3 - Partially dependent (5-10 hrs per day - 40+ weeks per year)LEVEL 2 - Marginally dependent (1-4 hrs per day - 40+ weeks per year)LEVEL 1 - Sporadically dependent (STA) can be supported by community supports if necessary
Are there other providers using these same funds?*

YESNO
Select how fees will be paid*

NDIS 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)
If NDIS through the portal paid - I authorise the quarantine of relevant nominated funds*

YesNoNot 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 CodePhone 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 / https://wonderlandretreat.com.au/about/policies www.piratesrest.com.au / https://piratesrest.com.au/about/policies/ 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 and plan to be using the service on a regular basis.

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 agree to an hourly time charge against the specific line item for the service for the creation of an Individualised Care and Activities Plan, special training for staff to implement the ICA Plan and/ or Behaviour Support Plan and Emergency support from the Management Team as may be required to fully support the needs of the participant whilst in the care of WCS. In the case of STA this will be charged as either pro rata on daily rates or 2:1 additional support in line items.

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

9. 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 7 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. For participants living in our SIL properties rental agreement cancellations and key terms policy still apply.

10. In the event of an emergency or disaster WCS will communicate clearly about the changes in support provision or measures to ensure participant safety and support to the participant/guardian/nominee and participant stakeholders and a plan will be provided to ensure continuity of care and critical supports are in place. I understand that it will be important to work with my provider for the best outcomes in an emergency situation. Emergencies may include loss of staff, sickness of staff, quarrantine issues, flood, fire, earthquake and even war. All efforts will be made to minimise disruptions to the service supports for me by Wonderland and to gain my consents to changes.

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

12. I understand that Wonderland Community Services, in their commitment to participant safety, has an internal policy that requires all medication and household chemicals in group homes to be stored in a secure location by staff.

Participants who self-administer their own medication may request access at any time, and staff will provide the medication promptly.

Participants who wish to use cleaning chemicals may also request access at any time, and staff will provide them promptly for use.

This arrangement is a safety measure and is not considered a restrictive practice. It is designed to protect all participants staying in our group homes and ensure that medication and chemicals are managed responsibly.

By signing this agreement, you acknowledge and agree to this practice.

13. 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 persistent 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

* Wonderland agrees to provide a 30 day notice to the participant where cessation of services are required due to the above limits to this agreement.

* By enrolling as a participant, you agree to our Terms of Use and release Wonderland Community Services (WCS) from any liability for injury, damage, or loss arising from or associated with any hosted activities, including the use of on-site trampolines.
4. 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. ............................................................................................................................................ Where a participant or guardian is not able to sign this document and a delegated representative provides a signature on behalf of the participant - a text message or voice recording should be provided to identify this authorisation by the participant or guardian. Where a Public Guardian is appointed - an official email from the Public Guardian providing authorisation of services is required to be filed with this document. In this case the COS may fill out and sign this form.
Date

DayMonthYear
Date
Participant/Parent/Guardian Name*

First NameLast Name
Relationship to Participant*
Participant/Parent/Guardian Email*
example@example.com
I have read the price guide as per our website link and understand the fees and charges that apply to me and this service agreement

YES
I have read the NOTES section below and agree

YES
I authorise my Plan Manager and/or Coordinator of Support to provide a full copy of my NDIS Plan to WCS so that creative options of service provision can be explored if required.

YES
Signature of Participant Or Authorised Representative

Clear
Wonderland's Representative's Name

First NameLast Name
Wonderland Email
example@example.com
Date

DayMonthYear
Date
Send ISA to:*
Signature

Clear
NOTES (explanation of this agreement)

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 services listed above.

2. Authorisation to contact agreed support and network personnel 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, and 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 & Capacity Building Supports. This includes an agreement for cancellation charges as identified within our cancellation policy document and a non-face-to-face support provision as per NDIS Price Guide recommendations. Authorisation of quarantining NDIS funds for service provision.

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

7. Understanding the limits of this agreement.
Version: 08/01/2024
Should be Empty:

INDIVIDUAL SERVICE AGREEMENT (ISA)

Service Agreement

Participant Details

Disability Information

1. Service/s Requested

2. Agreed Support Network Contact Details

3. Funding arrangements

FLEXIBLE FUNDING

SPECIFIED FUNDING

4. Signatures