Happy Dots Occupational Therapy Service Agreement

Occupational Therapy Service Agreement

This document contains important information about the services you are receiving from Happy Dots.

This Service Agreement pertains to:

Participant First Name: *

Participant Last Name: *

DOB: *

Address: *

NDIA Number: *

Parent/Carer:

Mobile: *

Email: *

Plan Start Date:

Plan End Date:

Service Agreement Start Date:

Service Agreement End Date:

OCCUPATIONAL THERAPY

Participation in Occupational Therapy is a collaborative process between you and your child, your therapist and anyone else you determine to be appropriate. At Happy Dots, we take a client-centred approach. You know your child, your family and your unique situation best. Your therapist will work with you to identify goals important to you and your child, and how best to achieve these goals. A consistent approach across all of your child’s environments including home, school/day care and therapy sessions, will see the best results for your child. Your therapist will work with you to determine the best way to implement recommendations and activities at home to ensure that your child is gaining the most from attending Occupational Therapy.

CONFIDENTIALITY:

There are laws that clarify the privacy of all communications between you, your child and your therapist. In most situations, your therapist can only release information about you if you sign a written authorisation form.

I,

parent/carer of

give permission for Happy Dots Occupational Therapy to liaise with the following services supporting my child:

Name

Service Provider

Role

Contact Details

DO YOU CONSENT TO HAPPYDOTS PROVIDING YOUR CHILD'S PLAN MANAGER WITH A COPY OF THIS SERVICE AGREEMENT FOR FUNDING AND INVOICING PURPOSES *

PLAN MANAGER DETAILS

Name of Plan Manager

Email Address for Plan Manager

Name

Service Provider

Role

Contact Details

Name

Service Provider

Role

Contact Details

Name

Service Provider

Role

Contact Details

The information will be factual in nature and only concern aspects relating to my child’s health. A copy of relevant written reports may be provided on request. Please be aware that any of the above information may be provided in verbal, written or electronic form.

I also authorise Happy Dots to photograph/video my child for the purpose of assessing and treating, information sharing with other agencies/health professionals for clinical purposes and training purposes.

Please notify us of any persons that you do not wish for us to share information relating to your child’s care.

SESSIONS:

Occupational Therapy Sessions can be conducted in the clinic at home, or a school, depending on your child’s needs and goals. Sessions usually consist of 45 minutes of therapy, with an additional 15 minutes spent by the therapist compiling notes, reviewing progress and goals, and following up on any recommendations for home and/or school.

Types of Therapy and Breakdown Cost:

Service	Price
Occupational Therapy Initial Assessment - Includes Report Writing and Report Feedback Session (Total 4 Hours)	$775.96
Occupational Therapy Follow up Re-Assessment	$387.98
Occupational Therapy Individual Sessions	$193.99 per hour
Occupational Therapy School/Home Visits where applicable	$193.99 per hour
Occupational Therapist Travel	$3.23 per minute
Occupational Therapy Reports (Indirect administration (eg. Reports, NDIS liaison, phone calls, visuals, social stories, session plans)	$193.99 per hour
Occupational Therapy Group Therapy Sessions	$86.79 per hour
Flying Start School Readiness Program (10 Sessions)	$1050.00 program
Occupational Therapy Assistant Individual Sessions	$86.79 per hour
Occupational Therapy Assistant School/Home visits where applicable	$86.79 per hour
Occupational Therapy Assistant Travel	$1.45 per minute
Occupational Therapy Assistant Reports (Indirect administration (eg. Reports, NDIS liaison, phone calls, visuals, social stories, session plans)	$86.79 per hour

CANCELLATIONS:

Happy Dots has a strict cancellation and ‘no show’ Policy. Your appointment time is a contract for exclusive use of the therapist’s time. Late cancellation and ‘no show’ fees are enforced to help cover the time your therapist has dedicated for your child’s appointment and session preparation.

PLEASE NOTE: NDIS cancellations with less than 48 hours’ notice or ‘no show’ will be billed at the rate of 100% of the session fee of $193.99 as stipulated by NDIS guidelines.

To avoid paying a cancellation fee you will need to advise us as soon as possible to cancel or reschedule your child’s session appointment. You can contact us on Ph. 4959 8920 or email us at admin@happydots.com.au

A cancellation fee will be charged when your appointment is:

Cancelled less than 48hours prior to your scheduled appointment session via email, phone or SMS or
You miss your appointment without notifying Happy Dots.

The occurrence of issuing 2 consecutive of late cancellation fees will result in the discontinuation of your therapy. The occurrence of 3 consecutive cancelling/rescheduling appointments will result in you losing your preferred allocated timeslot. Happy Dots reserves the right to cancel or reschedule an appointment if there are reasons for concern related to the therapist or child. Happy Dots bears no responsibility for any costs or loss of income that may be incurred. Happy Dots makes every effort to deliver scheduled appointments and provide you the earliest possible notice to any changes to your appointments.

"Disclaimer": Please note that any updates to the NDIS guidelines may override the conditions set out in this service agreement. This may include changes to NDIS pricing, travel requirements and/or cancellation fees, etc.

Please direct all enquiries to our administration team via email or phone.

HOURS

Type of Session

Quantity :

Rate ($):

Total Cost:

Occupational Therapy Initial Assessment - Includes Report Writing and Report Feedback Session (Total 4 Hours)

Occupational Therapy Follow up Re-Assessment

Occupational Therapy Individual Sessions - per hour

Occupational Therapy School/Home Visits where applicable - per hour

Occupational Therapist Travel - per minute

Occupational Therapy Reports (Indirect administration (eg. Reports, NDIS liaison, phone calls, visuals, social stories, session plans) - per hour

Occupational Therapy Group Therapy Sessions - per hour

Flying Start School Readiness Program (10 Sessions)

Occupational Therapy Assistant Individual Sessions - per hour

Occupational Therapy Assistant School/Home visits where applicable - per hour

Occupational Therapy Assistant Travel - per minute

Occupational Therapy Assistant Reports (Indirect administration (eg. Reports, NDIS liaison, phone calls, visuals, social stories, session plans) - per hour

TOTAL ($):

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Therapist: *

Therapist Signature *

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Date: *

I have read the above Service Agreement and understand all information that has been provided to me.

*

Parent/Guardian: *

Date: *

Client Financial Responsibility

I understand and agree that I am financially responsible for all charges for any and all services rendered where NDIS funding has been exhausted.

Payment in full for services and products are due at the time services are performed or products are ordered.

As the guarantor, it is your responsibility to know the participants NDIS benefits and to provide our clinic with the most up to date information.

Health and Safety Conditions of Service

We aim to ensure the protection and safety of all children, staff members, and families accessing our Service. Adequate supervision must be provided when children arrive and depart our premises. It is a condition of service that a parent / carer remains onsite (either in reception OR carpark) for the duration of appointment. Each child must be checked in with reception on arrival, please make reception aware that you have arrived for your session.

Signature *

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