Paticipant Detail

Paticipant*

Paticipant First Name Paticipant Last Name

Paticipant Date of Birth*

Paticipant Representation

Is the NDIS Participant being represented by someone else for the purpose of this agreement?*

Yes
No

Contact Details

Email*

Mobile*

Plan Management

How is this Plan Managed?*

Self Managed
Managed by a Plan Nominee
Managed by The National Disability Insurance Agency (NDIA)
Managed by a Plan Management Provider

Commencement

When does this agreement commence?*

At the start of the selected NDIS Plan
Today

Review

How often should this agreement be reviewed?*

every month
every 3 months
every 6 months
every 12 months

NDIS ID

Participant NDIS ID*

NDIS Plan Details

NDIS Plan ID*

NDIS Plan Start*

NDIS Plan End*

Services

I provide psychological support, including assessment, recommendation, therapy or training, which is charged at the NDIS approved hourly rate (Currently $214.41). Reports, school observations, and communication with other specialists and/or related parties (for example school guidance officer) can also be provided at request and are priced based on the hourly rate noted before.