Contact form 7 – Harmony Specialised Support

Please fill the form

Your Name *
NDIS Number *
This agreement has been made between Nicole Beardsley Occupational Therapy and *
Name of person responsible for signing on behalf of client
Relationship to client
Date services will commence (as per NDIS plan) *
End date (as per NDIS plan)*
Services Requested *
Hours of funding available for service *
Email Address *
Phone Number*
My funding is managed by *
Invoices are to be sent to the following email address for payment *
Plan Manager details
Telehealth All services are conducted using a private and secure telehealth platform. Telehealth will not be suitable for all participants. By signing this service agreement you are confirming the following: You are aware that services will be provided via telehealth and you will not have face to face consultations with your occupational therapist You have a device that can be used for video conferencing such as a computer, ipad or smart phone You have access to a secure and stable internet connection You have a support person to assist with communication, operating the device and to provide emotional support throughout the consultation if you require this support You have a private space to discuss sensitive information which will not be overheard (public spaces such as a library or cafe are not appropriate) You have the ability to consent to telehealth consultations or a person who has the authority to consent to this service on your behalf, taking into consideration your preferences and rights
Click this box if this form was filled in by the occupational therapist and verbal consent was obtained by the client/ authorised person to sign on their behalf Verbal consent obtained
Date
I have read and agree to the conditions in this service agreement
Your Signature

Connect With Us