Service Enquiry Client Details If you would prefer to download and fill out this form, you can download it here Service Agreement FormParticipants Name:(Required)Date of Birth:(Required) DD slash MM slash YYYY Parent/Caregiver name:(Required)Email:(Required) Phone Number:(Required)Address:(Required)NDIS PlanNIDS number:Start Date: MM slash DD slash YYYY End Date: MM slash DD slash YYYY A copy of the participant’s NDIS plan is attached to this Service Agreement (recommended) A copy of the participant’s NDIS plan is attached to this Service Agreement (recommended) Is the Plan funding: Plan Managed Agency Managed Self Managed Plan Manager:Email: Support Coordinator:Email: Phone:Services required:CORE - 01 Assistance with Daily LifeRespite Respite AmountCamps Camps AmountCORE – 04 Assistance with Social, Economic & Community ParticipationWeekend Group Day Excursions Weekend Group Day Excursions AmountMentoring 1:1 Mentoring 1:1 AmountDay Options Program Day Options Program (including Weekend Coffee Cart) AmountIndividual Community Access Individual Community Access AmountCB - 09 Increased Social & Community ParticipationWeekend Group Day Excursions Weekend Group Day Excursions AmountMentoring 1:1 Mentoring 1:1 AmountSocial skills training Social skills training AmountCB – 15 Improved Daily Living SkillsWeekend Group Day Excursions Weekend Group Day Excursions AmountMentoring 1:1 Mentoring 1:1 AmountSocial skills training Social skills training AmountDay Options Program Day Options Program (including Weekend Coffee Cart) AmountIndividual Community Access Individual Community Access AmountService Agreement SummaryThis Service Agreement is for(Required), a participant in the National Disability Insurance Scheme and A.H.H Lifeskills PTY LTD (Provider Number 40 500 143 29This Service Agreement will commence on DD slash MM slash YYYY for the period 12 months.This Service Agreement is made for providing supports under the participant’s NDIS 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 of supports InitialThe provider agrees to: once agreed, provide supports that meet the participant’s needs at the participant’s preferred times communicate openly and honestly in a timely manner give the required notice periods for cancellations as per our Cancellation Policy (see at www.ahhlifeskills.com) InitialThe participant/participant’s representative agrees to: inform the provider about how they wish the supports to be delivered to meet the participant’s needs talk to the provider if the participant has any concerns about the supports being provided give the required notice periods for cancellations as per our Cancellation Policy. (see at www.ahhlifeskills.com) The parties agree that any changes to this Service Agreement will be in writing, signed, and dated by the parties.InitialFeedback and Complaints If the participant wishes to give the provider feedback, the participant can talk to Adelaide Schiblhut on 0429 323 221 or info@ahhlifeskills.com If the participant is not happy with the provision of supports and wishes to make a complaint, please refer to our Complaints Policy, at ahhlifeskills.com If the participant is not satisfied or does not want to talk to this person, the participant can contact the National Disability Insurance Agency by calling 1800 800 110, visiting one of their offices in person, or visiting NDIS Commission for further information. A complaint can be made to the NDIS Commission by: Phone: 1800 035 544 (free call from landlines) or TTY 133 677. Interpreters can be arranged. InitialContact name : Adelaide Schiblhut Mobile : 0429 323 221 Email : info@ahhlifeskills.com, finance@ahhlifeskills.com The parties agree to the terms and conditions of this Service Agreement. Please refer to the entire agreement for complete details. InitialSignatureDate DD slash MM slash YYYY NameThis field is for validation purposes and should be left unchanged. Feedback and Complaints PDF Forms & Policies Summary Service Agreement Cancellations Policy Feedback & Complaints Policy Feedback Form Choice and Control and Dignity of Risk Policy Privacy & Dignity Policy AHH Price List
