Program of support

Participant Registration form

Group Programs

Intake phone call or in person at the Clinic 128 Yarra Street Geelong (30 mins)
Personalised program written by an Occupational Therapist (15 mins non face to face time)
3 hours session run by Occupational Therapist & Therapy Assista nt Level 2 - Min 3 participants - Max 6 participants per group
Written feedback notes after the program (15 mins non face to face time)

Cost per session: $365*

Total cost for 3 sessions: $1,095*

NDIS and Medicare rebates available

Medicare and private paying participants is required to pay at time of booking .

*Cost are calculcated at 193.99 per hour divided by the number of participants in the group.
Min 2 participants - Max 6 participants per group*

PARTICIPANT DETAILS

Participant’s First Name *

Participant's Last Name *

Date of Birth *

Phone

Email

Select your preference for the group sessions

Select the date and time of choice, we will send a confirmation after the form is completed if the preferred time is still available. Tick as many as options as you need. *

Private paying or Medicare Participants

Payment is required at time of booking. Our reception team will call and take payment once the form is submitted.

Cancellation Policy

Full refunds can be provided if cancelled within two weeks of the group start date. If cancelled within the two weeks period, no refund will be provided.

If you are a private paying or Medicare participant, please skip to the next part of the form (emergency information)

Program of support for NDIS participants

Fees are charged under Capacity Building – Improved Daily Living this includes 3 hours face to face group session, 30 mins non contact work (including planning and written feedback notes after the program) and 30 mins phone call or face to face session plus Centre Capital Cost $2.53 per hour. If additional time is needed to prepare the group session for the participant, more non-contact time will be allocated to the individual and not the group.

15_617_0128_1_3 Assessment Recommendation Therapy or Training - Occupational Therapist Rate $193.99

15_005_0118_1_3 Capacity Building for Early Childhood Intervention - Other Professional Rate $193.99

15_053_0128_1_3 Therapy Assistant - Level 2 Rate $86.79

15_008_0118_1_3 Early Childhood Intervention Therapy Assistant - Level 2 Rate $86.79

All prices will be adjusted if there is any change in the NDIS Pricing Arrangements and Price Limits during the progam of support period.

How do cancellations work for a program of support?

A program of support is an arrangement where a group-based supports provider enters into an agreement with a Participant for up to 6 months. During this arrangement, supports in the program can be claimed against the Participant’s plan regardless of whether or not they attended.Services that are operating under a program of supports approach are not subject to short notice cancellation rules. To exit a program of support, no more than 2 weeks of notice is required. 100% of the scheduled fee can be charged for sessions taking place during the 2-week notice period. The cost of sessions due to take place after the notice period should not be charged.

Funding

Plan ManagedSelf Managed (prepayment is required to book the group session)

Plan Manager's Email

EMERGENCY INFORMATION

Emergency Contact 1

Name *

Phone/Email *

Relationship *

Emergency Contact 2

Name

Phone/Email

Relationship

Does the participant require assistance in an emergency?

YesNo

Please provide details

HEALTH AND MEDICAL INFORMATION

Allergies / Alerts

Disability and / or Medical Conditions

RISK

Health Risk Summary

Outline any potential risks identified and strategies to mitigate them.

Description of Risk

Risk Level

HighMedLow

Action

Please upload a copy of any additional Risk Assessment material

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PROGRAM OF SUPPORT AGREEMENT

Signatures

By signing this Program of Support Plan, I agree that I have been involved in the development of my plan of care, my goals and the services required and I understand the cancellation policy. *

Participant/Representative Signature *

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Participant/Representative Name *

Date *

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