WP E-Signature by Approve Me - Sign Documents Using WordPress -

Service Agreement Contract

This is an agreement between Family Time Australia and for

I, agree to commence services for my Child with Family Time Australia.

Child's Name:

Parent/Carer's Name:

Parent/Carer's Email:

This service agreement is made for the purpose of providing transdisciplinary therapy intervention. For National Disability Insurance Scheme (NDIS) participants the parties agree that this service agreement is made in the context of the NDIS which aims to:

Support the independence, social and economic participation of people with a disability (or disabilities), 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.

What to expect from us:

We will ensure effective communication.
We will send you SMS reminders 48 hours before your appointment.
We will ensure that we set goals that are guided by you for the therapy intervention and/or participatory in our group sessions.
We will review our goals regularly together with you and assess our progress an outcomes as a team.
We will provide you with quality therapy services and programs and will ensure that we are providing you with information and education at all times. Services will be provided through different means including face to face, telehealth and phone consults.
We will issue regular invoices and statements of services delivered to you.

What we expect from you:

Please provide us with any relevant assessments or paper work that will best help us prepare for quality intervention.
We expect you to be an active participant of the team. You will guide us and educate us on your child and family.
When unable to attend an appointment please let us know within 48 hours of your appointment or fees may apply.
Please communicate with us regarding how things are progressing at home, if you are having any difficulties with the therapy intervention programs, or if there are other things going on in the family that we need to consider.
We appreciate all feedback, comments and suggestions. We respect this is your child and your journey and we are here to help.
For NDIS participants, services cannot be provided without the provision of an NDIS Plan. Please ensure this is provided immediately upon receipt of your NDIS Plan.
For Medicare participants, rebates cannot be applied without receiving your care plan documents prior to appointments.

Therapy Plan

Group Programs

My Child will be participating in Group Programs:

School Terms:

Term 1:
Term 2:
Term 3:
Term 4:

School Holidays:

January Holidays:
April Holidays:
July Holidays:
October Holidays:

Please be advised Group Programs are subject to availability. Group Enrolment Form needs to be completed to confirm participation.

Therapy Services

Family Time Australia provides therapeutic services with Speech Pathology, Occupational Therapy, Psychosocial Therapy and Nutritional Therapy.The treating therapist will support with identifying the most appropriate therapy plan including the following details:

Therapy service required
Joint sessions
Individual sessions
Frequency
Specified number of sessions with a relevant health professional

Therapy Plan:

School Visits

Number of School Visits:
School: Teacher's Name:
Visiting Therapist/s:

Home Visits:

Number of Home Visits:
Visiting Therapist/s:

Additional Support Required: If yes, details of support required:

I currently access other services:

Organisation: Treating Therapist: Frequency:
Organisation: Treating Therapist: Frequency:
Organisation: Treating Therapist: Frequency:

I understand the therapy plan may require changes

Yes

Funding

Chronic Disease Management Plan (CDMP)

Eligible: Referral to GP Required: CDMP Received:

Mental Health Care Plan (MHCP)

Eligible: Referral to GP Required: MHCP Received:

Helping Children with Autism Package (#135)

Eligible: Letter Received: Start Date: End Date:

Private Health: Name of Fund:

National Disability Insurance Scheme (NDIS)

My NDIS Plan is:

Self Managed

Plan Managed

Agency Managed

No NDIS Funding

Please refer below for the corresponding details.

Self Managed: The participant has chosen to self-manage the funding for NDIS supports provided under this Service Agreement. After providing those supports, the provider will send the participant an invoice for those supports for the participant to pay. The participant will pay the invoice on the day of service provision by cash, EFTPOS or direct deposit.

Plan Managed: The participant has nominated a Plan Management Provider to manage the funding for NDIS supports provided under this Service Agreement. After providing those supports, the provider will claim payments for those supports from the Plan Manager.

Plan Manager's Name:
Contact Number:
Plan Manager's Email:

Agency Managed: The participant has nominated the NDIA to manage the funding for supports provided under this Service Agreement. After providing those supports, the provider will claim payment for those supports from the NDIA. I agree that Family Time Australia will claim for services that I have attended since the commencement of this agreement, including the initial interview, team collaboration meeting, preparation of my funding schedule and my first therapy appointment. Please refer to the Agency Managed funding page for confirmation of agreed service booking amounts.

Agency Managed Service Booking Agreement

Line Item: Total Service Booking ($): Start Date: End Date:
Line Item: Total Service Booking ($): Start Date: End Date:
Line Item: Total Service Booking ($): Start Date: End Date:
Line Item: Total Service Booking ($): Start Date: End Date:

Other

Authorised by: Invoices Sent To: Notes:

Agreement

Therapeutic Intervention and Support

To ensure that my treatment plan and therapy intervention is in line with the best practice and to enable effective and quality service provision, I understand that units of service will be required for:

Treatment Planning
Therapeutic education to family members, other therapists, teachers/educators and others involved in your child's daily life. This education can be written, face to face, via telehealth and/or phone consults
Support and advocacy for NDIS Planning Reviews

All therapeutic intervention and supports will be invoiced for in line with adhering to best practice policies.

Confidentiality

All discussions will be treated with professional confidentiality. Exceptions occur when law may require disclosure of information where there is:

Suspected child abuse or neglect, past or present
Immediate, specific risk of harm to any individual
Subpoena of files by a court
If a significant crime had been committed

Recording and Storing Information

Notes will be taken during sessions and placed on your file
All files are kept in secure storage

Cancellation Policy

We understand that daily life and challenges can complicate attending your appointment. In the event that you cannot attend your appointment, please provide 48 hours notice. If you do not provide 48 hours notice or do not attend your appointment a fee will be applied. Cancellation fees are not covered under certain funding bodies or rebates. You will be entitled to the current NDIS cancellation policy if you are an NDIS client.

We trust that you understand that as a growing business your therapists time is valuable and we endeavour to provide quality services to our families and reduce waiting periods. Thank you kindly and we look forward to working with you.

Ending this Service Agreement

Should either party wish to end this Service Agreement, they must give 1 month notice. If either party seriously breaches this Service Agreement, the requirement of notice will be waived.

By signing below I agree to this service agreement with Family Time Australia.

Parent/Carer Name: Date:

Family Time Australia Representative: Date:

Leave this empty:

Your legal name

Your email address