Respite Service Agreement

Please carefully review the vital information provided below and complete the following form:

Purpose:

This agreement delineates the terms and conditions for engaging in Respite services provided by Harmony Human Services. By endorsing this agreement, both parties commit to adhering to the specified terms, covering all Respite bookings made and delivered within the indicated dates. Respite services are invoiced in accordance with the current NDIS Pricing Arrangements and Price Limits for each successive 24-hour period.

Harmony Human Services is dedicated to furnishing top-notch, client-centric Respite services tailored to each individual's needs. Clients actively participate in decisions regarding accommodation, meals, and activities.

Contact

Respite Service Agreement

This Respite Service Agreement is made between the Client and Harmony Human Services (Service Provider).

Participant Details

First Name

Last Name

Referrer Email:

Contact Number

Address

This Respite Service Agreement will start on:

And will end on:

REFERRER DETAILS (if applicable). Name and Company:

Referrer Relationship to Client:

Referrer Contact Phone Number:

NDIS Plan Number

Referrer Declaration (tick box): I have gained permission from the client to inquire about Respite on their behalf and to provide information required to fill in this Respite Service Agreement.

Plan Manager Company Name:

What support is required? Include Diagnosis/risk/medical conditions

RESPITE GOALS & PREFERENCES:

AGREEMENT SIGNATURES: The Client and the Service Provider agree to the terms set out above. By entering signatures in the below fields, constitutes your agreement to the information required in this Respite Service Agreement form.

Date Client Signed:

Referrer Signature (if applicable): I declare I have explained this Agreement in its entirety to the client who is entering into this Agreement.

Date Referrer Signed:

If Signed by a Nominee: I confirm that this agreement has been explained to the person receiving the services and that they agree to the terms and conditions as set out in this agreement.

Date Nominee Signed:

Thanks for submitting!

Service Provider Responsibilities and Conditions:

Collaborate with the client to fulfil Respite needs and goals outlined in their NDIS Plan.
Engage the client in Respite planning, ensuring choices align with budget allocations set by Harmony Human Services.
Safeguard client privacy and confidentiality.
Extend courtesy and respect to the client at all times.
Involve the client in service-related decisions.
Address client feedback promptly and resolve issues or concerns efficiently.
Possess adequate insurance and security checks for the safe delivery of services.
Maintain accurate records of services provided to the client.
Issue invoices reflecting services, costs, and payment due dates in line with current NDIS Pricing Arrangements and Price Limits.

Cancellations:

Upon written approval of Respite, some services may necessitate upfront payment for accommodation and/or ticketed activities, which may be non-refundable. Cancellations or changes to bookings made after agreement signing will incur charges to cover out-of-pocket expenses, plus a 10% administration fee.
Full charges for the entire Respite period will apply if the client cancels for reasons other than injury or significant illness requiring hospitalisation, including serious breaches listed in this document.
By endorsing this agreement, the client confirms sufficient funding for Respite and ensures no risk to Support Workers.

Client’s Responsibilities:

Settle the invoiced amount within 7 days (Self-Managed clients only).
Ensure adequate funds in the NDIS Plan to cover service costs.
Provide feedback to ensure service needs are met.
Treat Harmony Human Services with courtesy and respect.
Discuss and resolve problems or concerns promptly.
Notify of any changes to the NDIS Plan or contact details.
Provide the required notice to terminate this agreement.

Changing this Agreement:

Any alterations to this agreement require mutual discussion and agreement between the Client and Harmony Human Services. Changes must be documented, signed, and dated by both parties.
Ending this Agreement:
Either party must provide 2 weeks' notice to terminate the agreement, subject to potential cancellation fees. In the case of serious breaches, this agreement may terminate immediately, with applicable cancellation fees.
Serious breach examples include abuse, insufficient funds, inappropriate behavior, or unreasonable requests.

Respite Service Agreement

Participant Details

ACKNOWLEDGEMENT

OPEN HOURS