📄 Printable Service Agreement

📝 How to Complete the Service Agreement Form This guide walks you through each section of the Service Agreement and explains what information to provide. Once complete, you can print and return the form via post or email: Email: admin@sctherapysupport.au Post: PO Box 2034, Bomaderry NSW 2541 🔹 1. Need Help? If you need support completing the form, we can provide: Translated versions Easy Read formats Phone or in-person assistance Help from a trusted support person 🔹 2. Parties Involved Fill in: Participant’s Full Name NDIS Number NDIS Plan End Date 🔹 3. Agreement Type & Services Tick what applies: Adult or Paediatric Services required: Occupational Therapy Speech Pathology Group Programs Then fill in: Funding Allocated Tick if funding is: Entire plan Released in increments Use the table to note the periods and amounts Refer to page 4 of the form for typical agreement amounts. 🔹 4. Schedule of Supports (Treatment Plan) The allied health provider will develop this plan. It includes: Types and frequency of therapy Non-face-to-face supports (e.g., planning, reports) Travel time and caps See detailed tables on pages 5–6 for hourly rates. 🔹 5. Consent & Acknowledgement You confirm agreement to: Services and pricing Travel charges Report preparation NDIS price guide compliance 🔹 6. Responsibilities Provider: Includes respectful communication, privacy, safety, regular reviews, and participant choice (pages 7–9). Participant: Includes cancellation notice, accurate information, payment responsibility, and respectful interaction (pages 10–11). 🔹 7. Payment Method Tick your payment arrangement: Self-managed Plan-managed NDIA-managed Privately funded Invoices are due within 7 days, and assessments are charged at booking. See pages 11–12. 🔹 8. Terms, Privacy & Credit Reporting Outlines: Overdue fees Debt recovery procedures How your data is managed Full details on pages 13–15. 🔹 9. Changes or Termination Changes must be in writing One-month notice to end the agreement (except in serious breach) 🔹 10. Feedback & Complaints Options: Speak with the Business Manager at 02 4421 6013 Online: www.sctherapysupport.au/feedback Or contact the NDIS Commission directly 🔹 11. Access to Records Tick if you agree to allow: NDIS auditors to access your file Specific people (e.g., parent, coordinator) to view your records 🔹 12. Signature Must be signed by: You (or nominee/guardian) A director or senior team member from Shoalhaven Occupational Therapy ✅ Return Completed Form Scan/photo and email to: admin@sctherapysupport.au OR Post to: PO Box 2034, Bomaderry NSW 2541