Permission to consult / release information

We encourage collaboration with other professionals involved in your/ your child's care management. 

Please enter the names of any professionals or organisations that you would like us to be able to consult and share information with in support of {name46}, {mobile}.

KLC Counselling & Play Therapy provides best practice and evidence-based treatments and as professionals we are bound by the Australian Counselling Association and Play Therapist Code of Ethics. All treatments are specifically tailored for your particular situation, so your therapist will explain the intended treatment and any associated risks. No treatment will be provided without you and your child’s consent. Your child has the right to refuse treatment or withdraw from treatment at any time. If you have any concerns around the treatment being provided then we encourage you to raise these concerns with your counsellor. 

If at any time your child expresses that they are feeling unsafe or you are concerned for their safety, then we can try to schedule an appointment, however we are not an inpatient or  crisis service. Between sessions or outside of business hours please contact either your GP, Kids Helpline on 1800 55 1800, Lifeline on 13 11 14, your local Mental Health Line on 1800 011 511, or call 000 in a life-threatening emergency. Please ensure that your child has access to these phone numbers.

1. Prior to commencement of therapy, I was given adequate information to understand the nature of counselling and the process of Interplay Therapy/Humanisitc Play Therapy. This information included but was not limited to: the progessional identify and qualifications of the therapist, the potential benefits and risks of Child-Centred Play Therapy (CCPT) and Interplay Therapy/Humanistc Play Therapy and the issue of confidentiality and its limits.

2. I agree that I have sough and consent to participate in the CCPT/Interplay Therapy/Humanistic Therapy Process for {name46}with the therapist. 

I agree to be involved in the process and to regularly review the treatment progress and process.

3. I understand and agree that information regarding clients, including case records, is confidential. These records are kept secure and will only be released under the following conditions:

1. For the purposes of individual supervision
2. If it is determined by the therapist, that the client is a danger to himself/herself or to someone else.
3. The child or family disclosed abuse or the therapist has concerns regarding suspected child abuse.
4. There is a court order to disclose information or a request made through the Freedom of Information Act. 

I affirm that I am the legal guardians of {name46}.

My signature below affirms that I have read and understand the statements above, and that I voluntarily consent to therapy and Child-Centred Play Therapy for the child named above.

Payment terms

NDIS sessions are charged in line with NDIS guidelines at a rate of $193.99/60 minutes. 

Private sessions are charged at a rate of $150 (inc gst)/60 minutes. 

Payment will be invoiced at the end of each session and are required within 7 days* of the invoice date. We accept direct deposit payments.

No shows, failure to pay after session will result in further appointments having to be prepaid.

You have 7 days from the date of invoice to raise any issues with your Therapist.

*Unless variation is authorised by our Director. 

Cancellation policy
Attending sessions regularly means you’ll get the most from your treatment. We understand that sometimes life will get in the way of this, so if you need to change or reschedule an appointment please allow us at least 48 hours notice to organise to help someone else in that session time.

To cancel or change an appointment, email the therapist directly. A confirmation text will be sent to you 24 hours before your session, this is not a reminder to cancel message. Late reschedules will still be charged for the original session.

If you’re unable to give us at least 48 hours notice there will be a fee, as outlined below. Cancellations for Monday morning must be made on or before Friday morning. We’ll do our best to fill your appointment time with someone from our waiting list, and if we’re successful you won’t be charged. Cancellation fees are charged in accordance with the NDIS guidelines and Australian Counselilng Association guidelines.

Fees for missed appointments and appointments rescheduled or cancelled with less than 48 hours notice:

NDIS guidelines:

100% of the full session fee

Private guidelines:

1st occurrence: 50% of the full session fee
2nd occurrence: 100% of the full session fee

Cancellation fees will be invoiced, failer to finalise this invoice will result in termination of upcoming sessions.

If you have an in-person appointment, but you have been unwell with cold/flu symptoms and/or suspect you may have COVID, please contact us to change to a video appointment.

Charges

The following activities will be invoiced privately or charged to your NDIS Plan:

• Child sessions- 45 minutes
• Parent sessions 30 minutes -1.5 hours
• Writing notes after an appointment or phone call. We will charge 15 minutes per appointment.
• All appointments with your therapy team. If there is more than one therapist at an appointment, you will be charged for each therapist
• Parent/Carer update sessions 1 hour - 1.5 hours (held after approx every 5 child sessions.)
• Talking with you in person, by phone, text message and email (10min+)
• Completing assessments and reports (with your consent)
• Your therapy team talking to one another about your therapy and goals
• Writing a Therapy Service Plan, support letter or NDIS progress report. We will charge minimum 1.5 hours for a Therapy Service Plan and letter and 2-3 hours for an NDIS report.
• Completing mandatory reports required by other professional bodies under our duty of care
• Resources purchased soley in support of your child.

We don't charge for the following activities:

• Booking appointments with you
• Updating you and other people about how things are going by phone (<10min)
• Email (less than 10 minutes)
• Preparing for your therapy sessions
• Setting up your NDIS services
• Completing invoices and payments

This Agreement is for the participant in the National Disability Insurance Scheme, and is made between:
Client: {name46}
NDIS Number: {ndisNumber}
Representative:{parentcaregiver1}
Address: {homeAddress}
Contact Number: {mobile}
Email: {email}

and

Kelli Carza
KLC Counselling & Play Therapy
74 Torquay Road
Hervey Bay QLD 4655
ABN:29 741 688 373
Phone: 0478 359 705
Email: klc.counsellor@gmail.com

This agreement will start on signature date and continue until this Agreement is ended by you or us.

Rights and Responsibilities

We both have rights and responsibilities. They are:

• Be polite and respectful
• Communicate openly and honestly
• Provide regular updates
• Keep safe
• Tell each other when we need to change or cancel an appointment
• Tell each other if there are changes to your NDIS plan
• Keep all information private unless there are safety concerns
• Work together to resolve problems quickly
• To cancel your child’s appointment if they are showing symptoms of cold, flu or COVID.
• To cancel your child’s appointment if a member of your household has contracted COVID or have been deemed close contacts.
   

KLC Counselling & Play Therapy is responsible for providing services that meet your needs. We are also responsible for working within the law, including the National Disability Insurance Scheme Act 2013 and Rules, and Australian Consumer Law.

Feedback, complaints and disputes

We want to know when therapy is going well and when there may be issues.

You can give us feedback by:

• Contacting our director on 0478 359 705, or emailing klc.counsellor@gmail.com or going to www.klccounselling.com.au
   

Once we have received your feedback, a staff member will review your comments and take action if appropriate. We will contact you within a week to discuss your feedback and update you of any action taken.

If you would prefer to speak with someone outside of KLC Counselling you can contact these organisations: 

• National Disability Insurance Agency (NDIA) Phone 1800 800 110, email feedback@ndis.gov.au or visit one of their offices
•  Health and Disability Services Complaints Office (HaDSCO) Phone 1800 813 583, email mail@hadsco.wa.gov.au or visit their office

Charges

The following activities will be charged to your NDIS Plan:

• Child sessions- 45 minutes
• Parent sessions 30 minutes -1.5 hours
• Writing notes after an appointment or phone call. We will charge 15 minutes per appointment.
• All appointments with your therapy team. If there is more than one therapist at an appointment, you will be charged for each therapist
• Parent/Carer update sessions 1 hour -1.5hours (held after approx every 5 child sessions.)
• Talking with you in person, by phone, text message and email (10min+)
• Completing assessments and reports (with your consent/at your request)
• Your therapy team talking to one another about your therapy and goals
• Writing a Therapy Service Plan, support letter or NDIS progress report. We will charge minimum 1.5 hours for a Therapy Service Plan and letter and 2-3 hours for an NDIS report.
• Completing mandatory reports required by other professional bodies under our duty of care

We don't charge for the following activities:

• Booking appointments with you
• Updating you and other people about how things are going by phone (<10min)
• Email (less than 10 minutes)
• Preparing for your therapy sessions
• Setting up your NDIS services
• Completing invoices and payments

Cancellations

If you need to cancel or change an appointment, we ask that you give us 48 hours notice.

To cancel or change an appointment, email the therapist directly. A conformation text will be sent to you 48 hours before your session, this is not a reminder to cancel message. Late reschedules will still be charged for the original session.

If you miss an appointment or cancel within 48 hours, we will charge you the full cost of your appointment.

If you cancel often, we will discuss your therapy goals and what help you might need to attend appointments.

If we can’t find a solution then we may decide to stop services until you are able to attend your appointments.

Terms of Trade

You have chosen to manage all or part of your NDIS funding, or you may be using a Plan Manager. This means that we will send invoices to you or your Plan Manager after we have provided services.

• Invoices will be issued on the day of services provided. Payment is required within 7 days of the invoice date. Invoices can be paid by direct deposit if Plan or Self Managed. 
• You have 7 days from the date of invoice to raise any issues with your Therapist. 
• If payment isn’t received within 7 days we will send you a reminder email. 
• If payment isn’t received within 14 days our team will follow up with you again. 
• If payment isn't received within 21 days we will notify you that your services have been suspended. 
• If payment isn’t received within 42 days we will refer your case to a debt collection agency. 
• If payment isn’t received within 49 days you will be discharged from services. 
• We do not accept part payments for NDIS services and have the right to suspend services until the full amount is paid.

Changes to this Service Agreement.

If you would like to make changes to the services you are receiving, please speak with your Therapist or our Director.

Requests to change this Service Agreement must be made in writing by email and may result in us having to make changes to your service booking.

Ending this Service Agreement

Requests to end this Service Agreement must be made in writing with 2 weeks notice.

Any services provided during this notice period will be charged. If agreed, the notice period will be waived.

Storage, Access and Correction:

All Disability Professional Service Providers are bound by the Privacy Act 1988. KLC Counselling undertakes to adhere to the Australian Privacy Principles; which regulates how we may collect, use, disclose and store personal information and how individuals may access and correct personal information held about them. All information is stored digitally on a secure, password protected iPad.

For more information about how privacy is managed at KLC Counselling, please email klc.counsellor@gmail.com

You (or your representative) agree to:
· inform us about how you wish the supports to be delivered to meet your needs
· let us know immediately if your NDIS Plan is suspended, updated, reviewed, extended or replaced by a new NDIS Plan or you stop being a participant in the NDIS
· manage or make arrangements for the management of payment for all supports you receive, including ensuring appropriate funding is available for all supports agreed in your Schedule(s) of Supports
· treat us with courtesy and respect
· talk to us if you have any concerns about the supports being provided
· give us a minimum of 48 business hours’ notice if you cannot make a scheduled appointment; and if the
notice is not provided by then, our cancellation policy will apply
· give us the required minimum notice of 10 business days if you need to end this Agreement.

Schedule of Supports
We agree to provide you supports as set out in the Schedule(s) of Supports detailed below. The supports and their prices are set out in the below Schedule(s) of Supports, as applicable. The Schedule(s) of Supports can be updated as and when your support requirements change, or when your NDIS Plan changes, to reflect your current support needs at a specific point in time.
All prices are GST inclusive (if applicable) and include the cost of providing the supports. The National Disability Insurance Agency (NDIA) has set the prices for each Support and they may change from time to time.
We will apply price increases in line with updates to the NDIS Price Guide. Additional expenses (that is, things not included as part of your NDIS supports like entrance fees, event tickets, meals) are your responsibility and these are not included in the price for the support set by the NDIA.
Your Schedule(s) of Supports may change from time to time, as agreed with you or your representative.

So that we can make sure you receive the services you need, we require some important information contained within your NDIS Plan. You can provide us a copy of your plan, or you can show us your plan during a meeting with a KLC Counselling representative. You can also choose not to provide your plan to us, and just provide the specific information we need in order to deliver your supports.