Service Agreement — EPM Rehab

NDIS Service Agreement — EPM Rehab

1Participant details

Full namePlease enter the participant's name

Date of birthPlease enter date of birth

NDIS numberPlease enter the NDIS number

Phone

Email addressPlease enter a valid email

Address

Guardian / nominee (if applicable)

Relationship to participant

Emergency contact name

Emergency contact phone

2Plan management type

Plan manager / support coordinator name

Phone / email

NDIS plan start date

NDIS plan review date

3Health & clinical information

This helps EPM Rehab deliver safe, effective exercise physiology and meet NDIS Practice Standards for risk assessment and emergency planning.

Diagnosis & conditions

Primary diagnosis / disability & reason for referral

Other relevant medical conditions / comorbidities

Medications & allergies

Current medications (name, dose, frequency)

Known allergies

Adverse reactions

Current physical activity & function

Current activity level

Current exercise / supports already in place

Mobility aid used

Falls in last 12 months

Current pain (Y/N)

Pain scale (0–10)

Pain location / description

Precautions & risk factors

EPM Rehab uses this information to identify and manage risks associated with exercise delivery, supporting compliance with NDIS Practice Standards risk assessment requirements.

Precautions or contraindications to exercise

Risk management strategy (if applicable)

Individual emergency information

Preferred hospital

Ambulance membership

Emergency medications / equipment carried (e.g. EpiPen, GTN, insulin)

Specific instructions for responding to a medical emergency

Consent to health information sharing

I consent to EPM Rehab sharing this health information with:

4Service line items & pricing

	Item description	Unit	Rate

Rates shown are NDIS Pricing Arrangements & Price Limits 2025–26 (effective 24 Nov 2025), standard pricing area. Self-managed participants may negotiate a different rate with EPM Rehab.

5Travel & cancellation

Estimated travel distance (km, one way)

Travel rate

Travel cost (return)

$19.80

Short notice cancellation

100%

Notice required

48 hrs

Cancellation policy: A minimum of 2 clear business days (48 hours) notice is required to cancel or reschedule. Cancellations with less notice, or a no-show, will be charged as a Short Notice Cancellation at 100% of the agreed session rate. Travel costs already incurred may also be charged.

6Session details

Session frequency

Session duration

Session location

Commencement date

7Acknowledgement & signatures

I confirm I have read and understood the services, fees, travel costs ($0.99/km), and cancellation policy outlined in this agreement.

I confirm the health and clinical information provided is accurate and I will notify EPM Rehab of any changes to my health status.

I consent to EPM Rehab collecting and using my personal and health information for the purpose of delivering these services, in accordance with the Privacy Act 1988 (Cth).

Participant / guardian signature

EPM Rehab representative

Date

Agreement submitted

Your NDIS Service Agreement (including health & clinical information) has been emailed to EPM Rehab as a PDF. You can also download your own copy below.