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.
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:
What to expect from us:
What we expect from you:
My Child will be participating in Group Programs:
Please be advised Group Programs are subject to availability. Group Enrolment Form needs to be completed to confirm participation.
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:
Additional Support Required: If yes, details of support required:
I currently access other services:
I understand the therapy plan may require changes
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:
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.
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
Authorised by: Invoices Sent To: Notes:
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:
All therapeutic intervention and supports will be invoiced for in line with adhering to best practice policies.
All discussions will be treated with professional confidentiality. Exceptions occur when law may require disclosure of information where there is:
Recording and Storing Information
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
Signed by Family Time Australia
Signed On: August 14, 2020
If you have questions about the contents of this document, you can email the document owner.
Document Name: Service Agreement Contract
Agree & Sign