NDIS Agreement Form

    Client Details:





    Support Worker Details:



    Billing Information:



    Client Medical Information:

    The Pottery Studio is collecting this medical information in order to address the medical needs of students during class hours. E.g. Diagnosis, medical management, triggers, allergies.

    Medical conditions:

    Do you require any medical aids or devices:

    Client:

    Signature

    Person acting on behalf of client:

    Signature

    The NDIS and this Agreement

    This service agreement is for client a participant in the National Disability Insurance Scheme (NDIS) and is made between:

        support worker of company and;
        The Pottery Studio (ABN: 72 635 312 622) of 4/20 Brookes Street, Nambour, QLD, 4560)

    This Service Agreement is made for the purpose of providing supports under the clients NDIS plan. A copy of the clients NDIS Plan is/is not attached to this Service Agreement. 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 client 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.

    • NDIS plan to be provided to The Pottery Studio

    3. Schedule of supports

    The Pottery Studio agrees to provide the client therapy services. The supports and their prices are set out in the attached Schedule of Supports. All prices are GST inclusive (if applicable) and include the cost of providing the supports. Additional expenses (i.e. things that are not included as part of a client NDIS supports) are the responsibility of the client / clients representative and are not included in the cost of the supports.

    4. The Pottery Studio Responsibilities 

    The Pottery Studio agrees to:

    • review the provision of supports at least annually with the client;

    • once agreed, provide supports that meet the client's needs at the client's preferred times;

    • communicate openly and honestly in a timely manner;

    • treat the client with courtesy and respect;

    • consult the client on decisions about how supports are provided;

    • give the client information about managing any complaints or disagreements and details of The Pottery Studio cancellation policy;

    • listen to the client’s feedback and resolve problems quickly;

    • give the client a minimum of 24 hours notice if The Pottery Studio has to change a scheduled appointment to provide supports;

    • give the client the required notice if The Pottery Studio needs to end this Service Agreement (see "Ending this Service Agreement" below for more information);

    • protect the client's privacy and confidential information;

    • provide supports in a manner consistent with all relevant laws, including the NDIS Act 2013 and Rules, and the Australian Consumer Law;

    • keep accurate records on the supports provided to the client; and

    • will issue invoices and statements of the supports delivered to the participant as per the NDIA Terms of Business for Registered Providers as requested 

    5. Responsibilities of the client / client representative

    The client / client representative agrees to:

    • inform The Pottery Studio about how they wish the supports to be delivered to meet the client needs;

    • treat The Pottery Studio workers with courtesy and respect;

    • talk to The Pottery Studio if the client has any concerns about the supports being provided;

    • give The Pottery Studio the required notice if the client cannot make a scheduled appointment, noting that if the notice is not provided , The Pottery Studio cancellation policy will apply;

    • give The Pottery Studio the required notice if the client needs to end this Service Agreement (see 'Ending this Service Agreement' below for more information); and

    • let The Pottery Studio know immediately if the client NDIS plan is suspended or replaced by a new NDIS plan, or the client stops being a participant in the NDIS.

    6. Payments

    The Pottery Studio will seek payment for their provision of supports after the supports have been delivered.

    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, (Practice Name) will send the client / client representative an invoice for those supports for the client / client representative to pay. The client / client representative will pay the invoice by direct debit / EFT within 7 days.

    NDIA MANAGED – Although we are working towards this, we are not yet registered for NDIA Managed plans.

    PLAN MANAGED - Although we are working towards this, we are not yet registered for NDIA Managed plans.

    7. 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. 

    8.  Ending this Service Agreement 

    Should either party wish to end this Service Agreement they must give 2 weeks notice. If either party seriously breaches this Service Agreement the requirement of notice will be waived. 

    9. Feedback, complaints and disputes 

    If the client wishes to give The Pottery Studio feedback or is not happy with the provision of supports and wishes to make a complaint, the participant can talk to Name on 0400 000 000 or email

    If the client is not satisfied or does not want to talk to this person, at any time, they can make a complaint to the NDIS Commission. Complaints to the NDIS Commission can be lodged:

    • online at www.ndiscommission.gov.au; or

    • by phone on: 1800 035 544.

    10. Goods and Services Tax (GST) 

    For the purposes of GST legislation, the Parties confirm that: 

    • a supply of supports under this Service Agreement is a supply of one or more of the reasonable and necessary supports specified in the statement included, under subsection 33(2) of the NDIS Act, in the client's NDIS Plan currently in effect under section 37 of the NDIS Act;

    • the client's NDIS Plan is expected to remain in effect during the period the supports are provided; and

    • the client / client representative will immediately notify the provider if the client's NDIS Plan is replaced by a new plan or the client stops being a participant in the NDIS.

    11. Cancellation Policy 

    At The Pottery Studio we value consistent and high quality intervention. If you need to cancel an appointment it is recommended it occur before 3pm on the day before your appointment to avoid a cancellation fee. If you contact The Pottery Studio after 3pm the day before your appointment or on the day of your appointment there will be a cancellation fee of 90% charged to your account and payment due at your next appointment. Should your therapist arrive at your scheduled appointment and you and your child are not at home or at the location of the appointment with no prior notice, the scheduled session including travel will be charged at 100% of the scheduled fee for that session. Where The Pottery Studio cancels a support due to operational reasons, the service will be rescheduled at no penalty to either party. Where multiple cancellations or no shows occur in a 12-month period, The Pottery Studio will initiate contact with the family and their support network to establish the supports we are providing are best suited to the family dynamics and the needs of the child.

    12.  Contact details

    The Client Representative can be contacted on:





    The Pottery Studio can be contacted on:

    Name: Gaby Sheridan
    Mobile 0402 489 220

    The Pottery Studio reserves the right NOT to provide service or to cancel any future appointments for the client if you do not have sufficient funds in your plan or the plan expires. Any service fees not met by NDIS will be covered by your client / client representative.

    Emergency Contact #1


    Emergency Contact #2


    Price & Payment Information

    Standard Class / Monday – Friday ~ $60.00

    All prices will be adjusted if there is any change in the NDIS price guide during the service agreement period.

    14. Agreement signatures 

    The parties understand and agree to the terms and conditions of this Service Agreement.

    Signature of client representative: