Service Agreement

Child's Particulars

This is a permanent residence.This is an interim placement.
Please upload any court orders in place regarding this placement via the file upload section at the end of this form.

Parent / Carer's Particulars

Please upload documentation if there is a Family and Community Services Care arrangement in place via the file upload section at the end of this form.

Service Description

I understand that my child is participating in an Occupational Therapy session with Rebecca Middeldorp (Bec). This is a clinic-based therapy service. Sessions can interchange between the clinic, home and school environment.

Therapy Fee

The hourly rate is set at $193.99 per hour. Sessions are charged at 70 minutes ($226.32), which includes 50 minutes of face-to-face time for direct therapy and feedback to parents and/or teachers, and 20 minutes of non-face-to-face time for preparation, therapy planning, documentation, therapy session resource making, and short communications with external professionals.

Full assessments using formal standardised assessment tools will take approx. 1.5 hours direct assessment time which is inclusive of feedback and approx. 3 hours minimum scoring and report writing time. A Functional Capacity Assessment for NDIS purposes will be charged at the above hourly rate at a minimum of five hours.

• Travel is charged at the above hourly rates as well as $0.97c per kilometre as per the NDIS guidelines.
• OT ‘home programs’ programming will be charged at the above rates.
• Reporting for NDIS, progress reports, etc. will be charged at the above rates. A standard summary report is approx. one hour therapy time. Medicare or Health Fund letters are included in the service.

Rebates / Funding

Please indicate which form of funding you will be using (please tick).

Private Health: Please consult your provider to find out your rebate amount as this is dependent on your level of cover.Chronic Disease Management Plan (formally Enhanced Primary Care Plan): If your child has accessed another service in their lifetime, e.g. physiotherapy, speech therapy, psychology, a dietician, podiatrist, chiropractor or audiologist, for an ongoing condition then they may be eligible for this plan. This gives you a partial refund, for up to five separate sessions per calendar year.Mental Healthcare Plan: This is part of the Better Access to Mental Health Care Initiative. Medicare rebates (partial refund) are available for patients to receive up to 10 services per calendar year. This is given in two sets (usually six then four sessions) with a review from the referring doctor after each set. Please discuss this with me if you are unsure whether your child is eligible.NDIS (please complete information below).


At this stage, Steps to Strides Occupational Therapy can only accept self-managed or plan-managed clients. Please indicate how you are managing your NDIS funding:
Self-managedPlan-managed (specify below)


Please upload a copy of your NDIS plan via the file upload section at the end of this form.

Photo and Video Consent

Photos & videos can be used to assist with your child’s program. With school-based therapy, photos and videos explaining activities may be sent to parents/carers. These are then deleted.
I agree to photos / videos being used for parent feedback.I do not want photos / videos used for parent feedback.

Permission to release information.

Ongoing collaboration with other services will take place were applicable, to ensure the best outcomes for the child and family. Examples of services include Family and Community Services, psychology, speech therapy, paediatricians, teachers, physiotherapists, behavioural therapists, etc.
I agree that Rebecca Middeldorp (Bec) can contact the service below on the details provided. Any changes to this information need to be advised in writing.

Consent and Confidentiality

• I understand that information gathered may be recorded in my file and will remain confidential.
• I understand that my file could be accessed for the requirements of file audits such as State & Federal Government funding reporting purposes or healthcare fund requirements.

Payments

• Invoices are issued at the conclusion of each therapy session. This will be via the credit card system stored in our practice management system.
• Reminder notices for overdue payments will be issued via phone or email after seven days.
• If payments are not received within 14 days (two weeks) from the issue date of the invoice, a $30 late fee will be added to your next invoice. If therapy is concluding then the invoice will be re-issued with the late fee added. This fee will not be claimable under any health fund.
• If payments that are not received within one month of the invoice issue date, then therapy services will cease until the balance is paid. Your child’s time slot is not guaranteed to be held during this time.

Cancellations and Sickness

• You must contact Rebecca Middeldorp (Bec) via phone or email to cancel a session within 24 hours of a booked session. Failure to do so will result in the full fee being charged.
• Appointments that are cancelled by the therapist will not be charged. Every attempt will be made to reschedule where possible.
• You will need to cancel your session if your child is sick. If it is home-based therapy and the parent/guardian is sick then you will also need to cancel. If your child is sick and you have not notified your therapist, the therapy session will not commence but will be charged in full.

Parent / Carer's Service Agreement

I / we have read and understand the expectations for participating in Steps to Strides Occupational Therapy service. *
Signed by at least one parent and/or carer *

File Upload (Optional)

Max file size: 5Mb. Acceptable file types: PDF, DOC, ODT, PNG, JPG.