Department of Health and Human Services
Disability and Community Services
Self-Directed Funding Individual Support Plan and Agreement /

This agreement is between the Participant andthe Service Provider.

This agreement is to be completed by participant request by the service provider and participant and/or nominated person with an advocate or SDF Planner if requested.

Support is to be provided in accordance with the Principles of the Disability Services Act 2011.

Individual Support Plan Agreement
1. Contact Details
1.1 Participant / Name
Address
Email
Telephone Number Mobile Number
1.2 Nominated Person / Name
Relationship to Participant
Address
Email
Telephone Number Mobile Number
1.3 Service Provider contact / Service Provider
Contact Name
Contact Role
Telephone
2.Participant Preferences
Clear understandings between the Participant, nominated person, and the service provider need to be discussed and negotiated in the following areas:
2.1 Participant’s preferred level and type of involvement in staff selection, and the way the service provider will respond to Participant choice in this area.
2.2 Participant’s preferred level of involvement and approach to the design of their support program (includes for example attendance at on-going meetings and/or direct liaison with support workers)
2.3 Has the Participant been advised how to request a change in staffing or support arrangements. / Yes – detail
No
2.4 Has the Participant been advised of the Grievance procedures in relation to service provision or individual support workers and how to access these? / Yes – detail
No
3. Support Details
3.1 Service dates / From To
3.2 Review date
3.3 Regularsupport hours to be provided by Service Provider per annum / Yes hours per Week
3.4 Intermittent and/or one off support / Yes hours per Week
3.5 List of equipment to beprovided by the Service Provider for the Participant to use. Specify responsibility for its upkeep and maintenance.
3.6 Regular Support: Complete the table below for services that will be provided by the Service Provider to the Participanton a regular, weekly basis.
Day / Time (from – to) / Duration / Type / Location
Monday / From To
From To
From To / hrs mins
hrs mins
hrs mins
Tuesday / From To
From To
From To / hrs mins
hrs mins
hrs mins
Wednesday / From To
From To
From To / hrs mins
hrs mins
hrs mins
Thursday / From To
From To
From To / hrs mins
hrs mins
hrs mins
Friday / From To
From To
From To / hrs mins
hrs mins
hrs mins
Saturday / From To
From To
From To / hrs mins
hrs mins
hrs mins
Sunday / From To
From To
From To / hrs mins
hrs mins
hrs mins
3.7 Intermittent support/s or services: provide details of all service that will be provided to the Participant on an irregular or intermittent basis. This should include type of service, hours and frequency.

4. Agreement and Authorisation

We the undersigned agree that all arrangements and conditions specified within this Individual Support Plan and Agreementare correct.

Participant

Participant’s Name:……………………………………Signature: ...... …….………

Date:……/…..…/…….

and/or

Nominated Person

Nominated Person Name: …………………………Signature: ...... …….………

Relationship to Participant: …………………………Date:……/…..…/…….

Service Provider

Name: ...... ………...... ………..Position: ………...…………………….

Signature: ……………...... Date:...... /..……/…….

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