GrowthArc Client Agreement & Policy Pack

GrowthArc Client Agreement & Policy Pack

Complete the client agreement and policy pack using the fields from the source PDF. Required fields are marked only where clearly indicated.
Client Details
Date of Birth

MonthDayYear
Date
Residential Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Preferred Contact Method
Client Full Name

First NameMiddle NameLast Name
Emergency Contact
Emergency Contact Name

First NameLast Name
Emergency Contact Relationship
Authorised Representative
Authorised Representative Full Name

First NameMiddle NameLast Name
Authorised Representative Relationship to Client
Authorised Representative Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Authorised Representative Email Address
example@example.com
Support, Authority, and Funding
Support Information
This information helps us provide support in a way that is respectful, appropriate and tailored to the individual’s needs and circumstances. Is there anything you would like us to be aware of in relation to: communication preferences neurodivergence disability health considerations sensory sensitivities, anxiety, overwhelm or stress responses, workplace circumstances, support needs or diagnoses relevant to service delivery.
Copy of Relevant Document(s) Status
Legal Decision-Making Authority - Other
Funding & Payment Arrangement

Other
Plan Management Provider
Funding & Payment Arrangement - Other
Email for Invoicing
example@example.com
NDIS Participant Number
Signatures and Agreement
Name of Signatory
Relationship to Client
Signature of Signatory
Date of Signature

MonthDayYear
Date
Signatory Role
If signing on behalf of the client as
Other authorised representative
GrowthArc Representative Name
GrowthArc Representative Signature
GrowthArc Representative Date

MonthDayYear
Date
Should be Empty:

GrowthArc Client Agreement & Policy Pack

Client Details

Emergency Contact

Authorised Representative

Support, Authority, and Funding

Signatures and Agreement