Name *

Email Address *

Phone Number (Please enter a valid phone number) *

Date Of Birth *

Address *

Email: Support Coordinator/Plan Manager *

This Agreement will start *

This Agreement will end with the plan end date *

Hayee Group will be conducting your services as your intermediary's and or service provider *

Please Select your Services: *

NDIS Number - Starts with 43 *

Please Select your Services: *

Other (please specify) *

When would you be requiring a report? *

When is your plan end date? *

By clicking the submit button

Intermediary’s and/or service provider’s responsibilities: agrees to:​Make sure service recipient is supported to understand their service agreement and conditions using the language, mode of communication and terms that the participant is most likely to understand review the service with you in 6 months treat you with courtesy and respect; consult you on decisions about how your supports are provided; work with you to arrange for supports that fit your needs and at your preferred times; comply with the approved guidelines relevant to the funding; Listen to your comments and questions and resolve problems quickly; Keep and provide clear records on services provided to you. 9.Allow you to update or change the Service Agreement and anytime​​​Service recipient’s responsibilities: agree to:​Review, sign and return copies of monthly expenditure statements in a timely manner; Report any errors or inconsistencies in monthly reports without delay; Follow the approved guidelines of the funding; Work to make sure that the services and supports delivered meet my support needs; Treat you with courtesy and respect; Talk to if I have any concerns about the services or supports being provided; Give reasonable notice(outlined below)should I wish to cease this agreement; Comply with safe working practices; Not request support workers to provide services outside the agreement. 10. Give at least 48 hours (2 business Days) notice before the cancellation of a session otherwise a cancellation fee at the value of the booked session may be charged.​Ending this agreement:​Should either party require this agreement to end, we agree to give 2 weeks notice. Intermediary’s and/or service provider’s responsibilities: agrees to:​Make sure service recipient is supported to understand their service agreement and conditions using the language, mode of communication and terms that the participant is most likely to understand review the service with you in 6 months treat you with courtesy and respect; consult you on decisions about how your supports are provided; work with you to arrange for supports that fit your needs and at your preferred times; comply with the approved guidelines relevant to the funding; Listen to your comments and questions and resolve problems quickly; Keep and provide clear records on services provided to you. 9.Allow you to update or change the Service Agreement and anytime​​​Service recipient’s responsibilities: agree to:​Review, sign and return copies of monthly expenditure statements in a timely manner; Report any errors or inconsistencies in monthly reports without delay; Follow the approved guidelines of the funding; Work to make sure that the services and supports delivered meet my support needs; Treat you with courtesy and respect; Talk to if I have any concerns about the services or supports being provided; Give reasonable notice(outlined below)should I wish to cease this agreement; Comply with safe working practices; Not request support workers to provide services outside the agreement. 10. Give at least 48 hours (2 business Days) notice before the cancellation of a session otherwise a cancellation fee at the value of the booked session may be charged.​Ending this agreement:​Should either party require this agreement to end, we agree to give 2 weeks notice. If either party seriously breaches this agreement, then the requirement of notice maybe waived. *from NDIS Price Guide PDF* Short Notice Cancellations Where a provider has a Short Notice Cancellation (or no show) they are able to claim 100% of the agreed fee associated with the activity from the participant’s plan, subject to this Price Guide and the terms of the service agreement with the participant. A cancellation is a short notice cancellation if the participant:  does not show up for a scheduled support within a reasonable time, or is not present at the agreed place and within a reasonable time when the provider is travelling to deliver the support; or  has given less than two (2) clear business days’ notice for a support that meets both of the following conditions: o the support is less than 8 hours continuous duration; AND o the agreed total price for the support is less than $1000; or  has given less than five (5) clear business days’ notice for any other support. Providers can only claim from a participant’s plan for a Short Notice Cancellation of the delivery of a support item to the participant if all of the following conditions are met:  this Price Guide indicates that providers can claim for Short Notice Cancellations in respect of that support item; and  the proposed charges for the activities comply with this Price Guide; and  the provider has the agreement of the participant in advance (that is, the service agreement between the participant and provider should specify that Short Notice Cancellations can be claimed); - if you are self-managed, credit card details are required to process payments. - by agreeing you also consent that Hayee Group Staff and Therapists may use your details to contact other healthcare professionals on your behalf to help improve our services to you.

The terms and conditions outline that if you cancel within 48 hours (2 business days) of your session it will be billed and claimed for 100% of the NDIS charge. This is inline with the NDIS practice standards *

If you are booked for ongoing/repeated sessions ie. weekly, fortnightly or monthly and cancel more than one consecutive session and wish to keep your booking time - you will be charged 50% of the NDIS session rate for every future booking canceled consecutively *

Agreed Number of Sessions based on NDIS rates: *

The number of sessions required will depend on the therapists assessments/diagnosis and reports, and may change due to the clients needs throughout the duration of the plan: *

The session and travel rates are governed by the NDIS pricing guide. Travel charges depend on the location that the therapist is travelling from *

Signature *

Name of Advocate/Guardian if signing on the Participants behalf: