Berkman Academy

Berkman Academy

NDIS Referral and Billing Form
Full Name of NDIS participant (The client for the session)

First NameLast Name
NDIS Number
Name of Parent/Legal Guardian

First NameLast Name
Phone Number

Area CodePhone Number
Email
example@example.com
All sessions are run by a qualified counsellor and a member of the Australian Counselling Association (ACA), in line with NDIS guidelines.
Participant NDIS goals below (Write down or attach)
Attach participant NDIS goals

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Applicable funding line item:
Please discuss with your plan manager, support coordinator or NDIS representative if you are unsure which funding category is appropriate for your plan.
Berkman Academy – Service Delivery & Billing
Service Delivery and Non Face-to-Face Supports

Berkman Academy provides therapeutic and capacity-building supports that may include both face-to-face sessions and reasonable non face-to-face activities directly related to the participant’s goals.

Non face-to-face supports may include:

session preparation and planning
documentation and progress notes
communication with support coordinators, families, schools, or allied professionals
program design and therapeutic follow-up
These activities are delivered in accordance with the NDIS Pricing Arrangements and Price Limits and are billed at the applicable hourly rate when they directly support participant outcomes.

Non face-to-face time is typically brief and proportionate to the support delivered and will not exceed reasonable therapeutic requirements.
How is your NDIS funding managed?
Email for billing purpose
Which days is the client generally available for sessions? (Tick all that apply)
Signature: Signing this form confirms agreement to Berkman Academy’s service delivery and billing practices, including reasonable non face-to-face supports.
Plan Management Details
Plan Management Organisation name
Plan manager name
Plan Manager’s email
Plan Manager Phone Number
Should be Empty:

Berkman Academy

Plan Management Details