Services Agreement

Client or you:

First Name^*

Last Name^*

Phone^*

Mobile^*

Email^*

Date of Birth:^*

Street^*

Suburb

State

Postal Code

NDIS Number

Plan Start Date

Plan Expiry Date

Representative who can act for you (if any)

First Name

Last Name

Phone

Mobile

Email

Relationship to Client

Hope Health & Care Services to Invoice:

Us directly (self managed)/Plan Manager (plan managed)/NDIA directly (NDIA managed)/Plan Nominee (Plan nominee managed)

Key Details

Date of this Agreement

Scheduled Review Date Note: if the client is receiving personal support, more frequent reviews required

Monitoring of Worker Frequency Set out the frequency at which Hope Health & Care Services will undertake in-person supervision of the Worker.. it could be weekly, monthly, bi-monthly, quarterly or six-monthly dependent on the individual circumstances.

Other provider consultation frequency set out the frequency that will be used to engage with providers including health care and allied health providers who may be involved in providing Other Support Services to the Client in their home or in supporting the Client to access community-based activities

Communication preferences

Has the Client been provided this Agreement? Provide details of date and method of provision

ls the Agreement consistent with the Client lntake Form. lf not, why not?

Has the Client been supported to understand the Agreement?

Was a representative or advocate present {if applicable). Provide details.

Has the Client signed the Agreement?

Have we signed the Agreement?

Has a fully signed version of the Agreement been provided to the Client? Make a record of the circumstances if the Client did not receive a copy Of their Agreement.

signature*

Terms of Agreement