Department of Communities TasmaniaHOUSING, DISABILITY AND COMMUNITY SERVICES

Individual Support Plan and AgreementThis agreement is between the client and the Service Provider. The agreement details the total number of hours funded by the Individual Funding Unit and is used to establish the funding agreement. This agreement is to be completed by the Service Provider and Client with an advocate or Gateway Service Local Area Coordinator if requested.Support is to be provided in accordance with the Objectives, Principles and Standards of the Disability Services Act 2011 (TAS).

Individual Support Plan Agreement

1. Contact Details1.1 Client Name      

Address      

Email      

Telephone Number       Mobile Number      

1.2 Primary contact (if not client)

Name      

Relationship to client      

Address      

Email      

Telephone Number       Mobile Number      1.3 Service Provider contact

Service Provider      Contact Name      Contact Role      Telephone      

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2. Client PreferencesClients are to be involved, as far as possible, in the day-to-day management of their support program. Clear understandings between the client, other significant people such as their carer or advocate, and the organisation need to be discussed and negotiated in the following areas:2.1 Clients preferred level and type of involvement in staff selection, and the way the organisation will respond to client choice in this area.

     

2.2 Clients 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 client been advised how to request a change in staffing or support arrangements.

Yes – detail       No

2.4 Has the client 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 Details3.1 Service dates From       To      

3.2 Review date      

3.3 Regular support 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 be provided by the      

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3. Support DetailsService Provider for the client 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 client on a regular, weekly basis.

Day Time (from – to) Duration Type Location

MondayFrom       To      From       To      From       To      

      hrs       mins      hrs       mins      hrs       mins

               

               

TuesdayFrom       To      From       To      From       To      

      hrs       mins      hrs       mins      hrs       mins

               

               

Wednesday

From       To      From       To      From       To      

      hrs       mins      hrs       mins      hrs       mins

               

               

ThursdayFrom       To      From       To      From       To      

      hrs       mins      hrs       mins      hrs       mins

               

               

Friday From       To      From       To      

      hrs       mins

          

          

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3. Support Details

From       To      

      hrs       mins      hrs       mins

           

SaturdayFrom       To      From       To      From       To      

      hrs       mins      hrs       mins      hrs       mins

               

               

SundayFrom       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 client on an irregular or intermittent basis. This should include type of service, hours and frequency.

     

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4. Agreement and AuthorisationWe the undersigned agree that all arrangements and conditions specified within this Individual Support Plan are correct. ClientClient’s Name:       Signature: ..............................…….………

Date:      and/orPrimary Contact Primary Contact Name:       Signature: ..............................…….…Relationship to client:       Date:      Service Provider Name:       Position:      Signature: ……………..................................... Date:      

A copy of this Agreement must be submitted to the Individual Funding Unit, by the Service Provider, in order for the funding agreement to be established between the Service Provider and the Department of Communities Tasmania. The Individual Funding Unit will not fund services that commence before the receipt of the signed ISPA and exchange of contract between DHHS and the provider.

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