ABN: 33 648 888 608

NDIS Service Agreement

NDIS Service Agreement

A Service Agreement can be made between a Client or their Authorised Representative (e.g. NDIS Plan Nominee, a parent, guardian or other nominated person) and a Provider.

In this Service Agreement, the term "Party" or "Parties" refers to Jump Start Therapy Services and the Client/Client's Authorised Representative who is making this Agreement.

Client Details

This Service Agreement is for (type Client's Name):

Client First Name *

Client Last Name *

The Person that is Authorised to sign this Service Agreement is:

The Client? *

The Authorised Representative? *

Client's Authorised Representative *

This Service Agreement is between the Client/Authorised Representative and

Please check this box if a Hardcopy is required of this Service Agreement

The NDIS and this Service Agreement

This Service Agreement is made for the purpose of providing supports under the Client's National Disability Insurance Scheme Plan.

The Parties agree that this Service Agreement is made in the context of the NDIS, which is a scheme that aims to:

- Support the independence and social and economic participation of people with disability, 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.

Contact Details

Client First Name

Client Last Name

Client Date Of Birth *

NDIS Number *

Phone

Email

Address *

Client Representative Name

Client Representative Phone *

Client Representative Email *

Client Representative Address

Relationship to Client

Schedule of Supports

Services requested in this Service Agreement *

Occupational Therapy

Send Service Agreement to the Referrer

Is this a NDIS Plan with a start date after 19/5/2025? *

YesNo

Funding Periods and Service Delivery:

The NDIS has introduced total plan budgets and funding periods for new NDIS Plans with a start date from the 19/5/2025. The Schedule of Supports below outlines the total plan duration along with the funding allocated to each funding period. Please note the following:

If there are any unused support hours at the end of a funding period, Jump Start Therapy Services will automatically roll these over to the next funding period to support continuous service delivery.
If the allocated hours for a funding period are exhausted, services will be paused until the start of the next funding period, unless we are notified of additional funding being made available in the current funding period.
If additional funding is required beyond the agreed total in the current Schedule of Supports, Jump Start Therapy Services will communicate this to the Participant/Plan Nominee and provide an amended Schedule of Supports for their approval.

Service Start Date (usually start of NDIS Plan or date services commenced in this Plan) *These are the dates in which Jump Start Therapy Services will be providing supports

Service End Date (usually end of NDIS Plan) *

Funding Period 1 - Start Date *

Funding Period 1 - End Date *

Funding Period 1 - Original Funding allocated to Occupational Therapy *

Funding Period 1 - New Funding allocated to Occupational Therapy

Funding Period 2 - Start Date

Funding Period 2 - End Date

Funding Period 2 - Original Funding allocated to Occupational Therapy

Funding Period 2 - New Funding allocated to Occupational Therapy

Funding Period 3 - Start Date

Funding Period 3 - End Date

Funding Period 3 - Original Funding allocated to Occupational Therapy

Funding Period 3 - New Funding allocated to Occupational Therapy

Funding Period 4 - Start Date

Funding Period 4 - End Date

Funding Period 4 - Original Funding allocated to Occupational Therapy

Funding Period 4 - New Funding allocated to Occupational Therapy

Total amount allocated to Occupational Therapy in Plan Period

Update on Current Service Agreement for this Plan Period

Previously Agreed Occupational Therapy Funding AmountIf new NDIS Plan dates, put "0"

Increase/Decrease in Occupational Therapy Funding amountAdditional $ Required

Please note that amount "Previously Agreed Funding Amount" box is a reflection of the funding previously AGREED to and the "Total" figures below incorporates the further funding requested.

This is the maximum funding requested. We will not bill for time that we do not use.

Occupational Therapy Budget TotalThis is the grand total of the service agreement

Funding allocated to Occupational Therapy in this Plan Period *Additional $ Required

Clinician

Alison (Occupational Therapist) Ph: 0410 309 638Linda (Occupational Therapist) Ph: 0428 300 178

Clinicians Email

alison@jsts.com.aulinda@jsts.com.au

Type of Support *

Capacity Building - Improved Daily Living - Therapy Supports - Occupational TherapistCapacity Building - Improved Daily Living - Early Childhood Supports (younger than 7 yrs old) - Early Childhood ProfessionalCore - Disability Related Health Supports - Therapy Supports - Occupational TherapistCore - Disability Related Health Supports - Early Childhood (younger than 7yrs old) - Occupational Therapist

Description of Support:

For Occupational Therapy, the service delivery details (including frequency and duration of services) are to be negoatiated with the Client/Client's Authorised Representative.

Price and Payment Information:

- The hourly rate is in accordance with the conditions stated in the NDIS Pricing Arrangement and Price Limits and Jump Start Therapy Services Information about Fees and Services. The hourly rate, travel rates and guidelines for services (including cancellation policy) will be subject to change, in accordance to changes to the NDIS Pricing Arrangement and Price Limits, or at Jump Start Therapy Services discretion.

- Click here to review information regarding our Fees and Services. Signing this Service Agreement indicates your consent to these Fees and Services.

Funding

Jump Start Therapy Services will seek payment for their provision of supports after the supports have been delivered in accordance with the clients plan funding type noted below:

SELF MANAGED - The client / client representative has chosen to self-manage the funding for NDIS supports provided under this Service Agreement. After providing those supports, Jump Start Therapy Services will send the client / client representative a Tax Invoice for those supports for the client / client representative to pay. The client / client representative will pay as per the Terms stated on the Tax Invoice.PLAN MANAGED - The client has nominated a Plan Management Provider to manage the funding for NDIS supports provided under this Service Agreement. After providing those supports, Jump Start Therapy Services will claim payment for those supports from:

Email for billing

Plan Manager *

Plan Manager Phone *

Plan Manager Email *

Plan Manager Address

The Client or Authorised Client Representative would like a copy of all invoices

YesNo

Payments

Jump Start Therapy Services will seek payment for their provision of supports after supports have been provided.

For NDIS plans that are self managed, managed by the Client's Nominee or Plan Managed by a Registered Plan Management Provider, Jump Start Therapy Services will send a Tax Invoice to the nominated person or organisation.

How and when to pay is stated on the Tax Invoice. Please check that the nominated person or organisation can meet these terms. We may put services on hold if these terms and conditions aren't met.

Copy of Client's NDIS Plan

To ensure we are providing services aligned with the Participant's goals and funding, we kindly request a copy of the current NDIS Plan. This assists us when applying for Assistive Technology, Home Modifications, Home and Living Supports or to help us to understand the other supports you receive funding for and identify any gaps.

NDIS Plan for the current period

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Copy of relevant diagnostic, medical, allied health or other reports/documents

To ensure we consider all relevant information, please provide any diagnostic, medical or allied health reports, Positive Behaviour Support Plans or other documents/reports.

Relevant documents

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Changes to this Service Agreement

If changes to the supports or their delivery are required, the Parties agree to discuss and review this Service Agreement. The Parties agree that any changes to this Service Agreement will be in writing, signed, and dated by the Parties.

Ending this Service Agreement

Should either Party wish to end this Service Agreement they must give two weeks notice.

If either Party seriously breaches this Service Agreement the requirement of notice will be waived.

Signatures

Are all details correct?

Yes - proceed to signing Service AgreementNo - please review and update

Notes:

I consent for my Signed Service Agreement to be provided to:

My Support CoordinatorOther

Support Coordinator Name

Support Coordinator Email

Other Person's Name

Other Person's email address

If you have a Plan Manager, we will automatically send them a copy of your signed Service Agreement so they can assist you with managing your NDIS Plan.
Ticking this box indicates your consent.
Choosing not to share relevant parts of your NDIS Plan may effect our ability to provide you with the services you need.
Please contact Alison McDonald if you do not consent for us to send a copy of your Service Agreement to your Plan Manager. *

By signing this Agreement, you agree to all of the information included.

Please note, if we do not receive back a signed copy of this Agreement and the Client continues to attend appointments after receiving, it is implied the Client / Client's Authorised Representative have accepted the terms within this Agreement.

I have read & understood this Service Agreement and understand each item listed within. I understand Jump Start Therapy Services will be engaged to provide services that it is entitled to receive payment in return.

I have read and agree to the Fees and Services *

I confirm that authority has been delegated to me the undersigned, to represent the Client and execute this Agreement as the Client's Authorised Representative.

Signature *

Draw signature|Type signatureClear

Authorised representative

Date

Signed on behalf of:

Client

Date

Thank you - we will review your response promptly and return an updated form for you to approve. Please hit "Submit" button below to proceed.

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