Evolve Private Service Agreement

A Service Agreement can be made between a Client or their Authorised Representative (e.g. a parent, guardian or other nominated person) and a Provider.

In this Service Agreement, the term "Party" or "Parties" refers to Evolve Therapy Collective (Evolve TC) and the Client/Client's Authorised Representative who is making this Agreement.

Client Details

Client First Name *

Client Surname *

The Person that is Authorised to sign this Service Agreement is:

The Client? *

The Authorised Representative? *

Client's Authorised Representative *

and Practice Name

Referrer Name

Referrer Email

Service Agreement Purpose

This Service Agreement is made for the purpose of providing supports to the Client.

Contact Details

Client First Name

Client Last Name

Client Date Of Birth *

Phone

Email

Address

Client Representative Name

Client Representative Phone *

Client Representative Email *

Client Representative Address

Relationship to Client

Schedule of Supports

Any particular stipulations to be included in this Service Agreement

Service Start DateThese are the dates in which Evolve Therapy Collective will be providing supports

Service End Date

Supports to be provided *

Occupational TherapyPhysiotherapy

Please prepare my funding in

Occupational Therapy Dollars *

Occupational Therapy Hours *

Physiotherapy Dollars *

Physiotherapy Hours *

Total Dollars

Budget Allocation Hours

Total Hours

Budget Allocation Dollars

Occupational Therapist *

Email *

Physiotherapist *

Email *

Type of Support:

Clinical assessment and treatment
Clinically relevant communications including phone calls/written programs/communication with other health professionals (any task that takes more than 6 minutes will be invoiced)
Attendance at team meetings/case conferences
Assessment and trial of equipment as required
Any reports, forms, or letters as requested by the client / client representative
Cancellation charges for late notice or no show appointments

Evolve TC reserves the right NOT to provide service or to cancel any future appointments for the Client if invoices are not paid.

Price and Payment Information:

- The hourly rate, travel rates and guidelines for services included (including cancellation policy) are subject to change. The fees are:

Occupational Therapy: $215.00 + GST per hour plus $215.00 + GST per hour for any associated therapist travel.
Physiotherapy: $215.00 + GST per hour plus $215.00 + GST per hour for any associated therapist travel.

If any Evolve TC Therapist arrives to a confirmed appointment, and the Participant declines service, is not present or does not show up after contact attempts, then both non-attendance of the appointment and any relevant travel will be charged.

Consent

At times, it may be helpful for us to talk with other people involved in your care. Only information relevant to the service we are providing will be discussed. We will not talk with anyone that you do not want us to speak with.

The Client/Client Representative consents to Evolve TC specifically liaising with:

Payments

Evolve TC will seek payment for their provision of supports after the supports have been delivered in accordance with the Clients funding type noted below:

Funding Other

Name of person/organisation paying *

Phone of person/organisation

Email of person/organisation paying *

Address of person/organisation

Payment is due by Electronic Funds Transfer within 14 days of invoicing.

Evolve Therapy Collective - a.b.n. 88 268 331 421

Copy of Referral

With the Client/Client represtative's consent, please provide a copy of the referral (e.g. Chronic Disease Management Plan), the Client's medical summary (if relevant) from their doctor and/or relevant allied health or other reports.

Referral

Browse

Medical Summary

Browse

Allied Health or Other Reports

Browse

Rights & Responsibilities

Evolve TC agrees to;

Provide Therapy services as per this agreement.
Work in collaboration with you to achieve your goals.
Communicate openly and honestly with you.
Be polite and friendly and treat you with respect at all times.
Explain things clearly so you understand every step of the process.
Include you in all decisions about your supports.
Listen to your feedback and act quickly upon any complaints you report to us.
Store your information carefully and maintain your privacy

You agree to;

Notify Evolve TC about any changes you wish to be made to this Service Agreement.
Provide at least 48 hours notice if you wish to cancel a booked service.
Provide at least 48 hours notices if you wish to terminate our services. You will be billed for the hours of service provided to the date of termination.
Pay invoices by the due date.

Cancellation Policy

Short notice cancellations or non-attendance, where notice is given with less than 2 clear business days before the scheduled appointment, may result in 100% of the appointment fee being charged (except in extenuating circumstances), including any travel (or part thereof) already undertaken.

If there are frequent cancellations, Evolve TC will contact you to try to understand why they are occuring and see if anything needs to change in the delivery of the therapy services to support the Client.

Outstanding Fees

Outstanding fees need to be paid prior to further services being provided. If fees are not paid, Evolve TC may contact the following (where applicable) to recover the outstanding debt:

- Debt collector

- The Client/Client's Representative will be liable for the costs associated in recovering such debts.

Making a Complaint

We will strive to ensure that your experience with Evolve TC is a positive one, however in any instance where you are unhappy with our service, feel free to discuss this with us as soon as possible. Please be assured that we welcome all feedback and will endeavour to resolve any issues or concerns in a timely manner.

If you have a concern, please complete our feedback form via this link.

If you have a concern, you can speak directly to either of the Evolve TC directors:

Angie Brown Fiona Williams
T: 0437 214 077 T: 0431 574 040
E: angie@evolvetc.com.au E: fiona@evolvetc.com.au

Changes to this Service Agreement

If changes to the supports or their delivery are required, the Parties agree to discuss and review this Service Agreement. The Parties agree that any changes to this Service Agreement will be in writing, signed, and dated by the Parties.

Ending this Service Agreement

Should either Party wish to end this Service Agreement they must give 48 hours notice.

If either Party seriously breaches this Service Agreement the requirement of notice will be waived.

Signatures

Are all details correct? *

Yes - proceed to signing Service AgreementNo - please review and update

Review Note

I consent for my Signed Service Agreement to be provided to:

my Representative

Client Representative Email

By signing this Agreement, you agree to all of the information included.

Please note, if we do not receive back a signed copy of this Agreement and the Client continues to attend appointments after receiving, it is implied the Client / Client's Authorised Representative have accepted the terms within this Agreement.

I have read & understood this Service Agreement and understand each item listed within. I understand Evolve TC will be engaged to provide services that it is entitled to receive payment in return.

I confirm that authority has been delegated to me the undersigned, to represent the Client and execute this Agreement as the Client's Authorised Representative.

Signature *

Draw signature|Type signatureClear

Date

Client

Signed on behalf of:

Client

Date

Thank you - we will review your response promptly and return an updated form for you to approve.

Please hit "Submit" button below to proceed.

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