PaticipantParticipant First Name* Participant Last Name* Participant Date of Birth* Day Month Year Participant RepresentationIs the NDIS Participant being represented by someone else for the purpose of this agreement?* Yes No Representative First Name* Representative Last Name* Contact DetailsEmail* Mobile*Plan ManagementHow 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 HiddenPayment TextPlan Nominee Organisation* Plan Nominee Contact* Plan Nominee Email* Plan Nominee Phone*Plan Manager Organisation* Plan Manager Contact* Plan Manager Email* Plan Manager Phone*CommencementWhen does this agreement commence?* At the start of the selected NDIS Plan Today ReviewHow often should this agreement be reviewed?* every month every 3 months every 6 months every 12 months NDIS IDParticipant NDIS ID* NDIS Plan DetailsNDIS Plan ID* NDIS Plan Start* Day Month Year NDIS Plan End* Day Month Year Indicate which Support Categories [Support Budgets] are on the Plan* Assistance With Daily Life [Daily Activities] Improved Daily Living Skills [CB Daily Activity] Improved Health & Wellbeing [CB Health and Wellbeing] Finding and Keeping a Job [CB Employment] Assistance with Daily LifePsychology QuantityAssessment, Recommendation, Therapy and/or Training (including Assistive Technologies). To be delivered by a Psychologist. Price: $ 214.41 Quantity Occupational Therapy, Speech Pathology or Social Work QuantityAssessment, Recommendation, Therapy and/or Training (including Assistive Technologies). Price: $ 193.99 Quantity Dietetics QuantityDietitian Consultation And Diet Plan Development. Individual advice to a participant on managing diet for health and well-being due to the impact of their disability. Price: $ 193.99 Quantity Total for Assistance With Daily Life Price: $ 0.00 Improved Daily Living SkillsPsychology QuantityAssessment, Recommendation, Therapy And/Or Training (including Assistive Technologies). To be delivered by a Psychologist. Price: $ 214.41 Quantity Occupational Therapy, Speech Pathology, or Social Work QuantityAssessment, Recommendation, Therapy And/Or Training (including Assistive Technologies). Price: $ 193.99 Quantity Counselling or Provisional Psychology QuantityIndividual Counselling. Facilitating self-knowledge, emotional acceptance and growth and the optimal development of personal resources on a one to one basis. Assist participants to work towards their personal goals and gain greater insight into their lives. Price: $ 156.16 Quantity Dietetics QuantityDietitian Consultation And Diet Plan Development. Individual advice to a participant on managing diet for health and well-being due to the impact of their disability. Price: $ 193.99 Quantity Therapy Assistance QuantityAllied health assistant (level 2) working under the delegation and supervision of a therapist, where the therapist is satisfied that the allied health assistant is able to work independently without direct supervision at all times. The allied health assistant must be covered by the professional indemnity insurance of the supervising therapist (or the therapist’s employing provider). Price: $ 86.79 Quantity Therapy Assistance – Community Engagement QuantityProgram to empower participants and improve interactions between participants and their social networks. Assistance to engage effectively in t\he community through a group approach to help achieve goals, gain insight into their lives and make informed decisions. Price: $ 43.48 Quantity Multidisciplinary SupportsMultidisciplinary team Total for Improved Life Skills Price: $ 0.00 Improved Health and WellbeingDietetics QuantityDietitian Consultation And Diet Plan Development. Individual advice to a participant on managing diet for health and well-being due to the impact of their disability. Price: $ 193.99 Quantity Total for Improved Health and Wellbeing Price: $ 0.00 Finding and Keeping a JobOccupational Therapy QuantityEmployment Related Assessment And Counselling. Workplace assessment conducted by a workplace rehabilitation provider to determine adjustments or modifications to the workplace or work processes to ensure employment is maintained and matches the employee’s capabilities. Price: $ 193.99 Quantity Total For Finding and Keeping a Job Price: $ 0.00 Grand TotalGrand Total Price: $ 0.00 HiddenService Schedule TextEmailThis field is for validation purposes and should be left unchanged.