NDIS Consultation / Hire Form

Thank you for contacting Kidsafe Qld.

In this form we refer to 'client' as the person requiring consultation or requiring mobility support. So that we can reduce wait times, we appreciate you taking the time to answer the questions and giving contact details of all the parties concerned.

If you have difficulties completing the form, please contact us on 07 3854 1829

As the person completing the form, what is your relationship to the 'client'? *

How can we help you? *

Has the 'client' had a consultation with us before? *

YesNoNot sure

This allows us to give you continuity of care and refer back to previous consultation notes.

Parent/Carer contact details

First Name: *

Last Name: *

Home Address: *

Email address: *

Phone Number: *

Allied Health contact details

Company: *

First name *

Last name: *

Office address: *

Email address: *

Phone: *

Funding details

NDIS Client Number *

NDIS Plan dates if applicable *

How are you funded through NDIS *

If 'other' please give more details

Send invoice/ quote to: *

Parent/CarerAllied HealthPlan ManagerAgency

Company name: *

First name: *

Last name: *

Email address: *

Phone: *

Client information

Client's first name: *

Client's last name: *

Date of birth *

So that we can select the right products to suit the client's needs, we need to know more about their physical size.

Client's approx. overall height (cm) *

Client's approx. torso height (cm) *

Client's approx. weight (kg) *

Client's chest circumference (cm): *

Client's chest width / diameter (cm): *

Client's waist circumference (cm): *

What other medical information should we know?

We understand that it can be complex to specify a medical condition and that there can be multiple factors. The above information is just to give us a snapshot and we will gather all information during the consultation

Additional information

The make and model of the vehicle will inform which products we recommend. It is also necessary that the noted vehicle is present at the initial consulation appointment.

Vehicle 1 Make & model *

Vehicle 2 Make and Model

Position in the vehicle: *

Type of seat the harness will be mounted to: *

What is the reason for the harness being used? *

Current child car restraints/ harnesses/ accessories being used *

What is the issue you would like us to address? *

Are there any specific products you would like to trial? Please include size *

What is your preferred appointment date: *

Your preferred appointment time: *

Preferred location for the consultation *

Address: *

Service agreement & fees

In-person Consultation Fees | Seating Solutions

1. In-person consultation fee is $193.00 per hour or part thereof within the Brisbane CBD.

2. For South East Qld locations outside of the Brisbane CBD, travel time will be added to the consultation fee at a rate of $193 per hour or part thereof.

3. Service bookings are required before consultation appointments can be confirmed.

4. An invoice for consultations wi ll be issued at completion of the appointment and payable within 14 days

5. Consultation fee/s are payable by client even if funding is not approved/ available and regardless of the quotation being accepted.

6 . A fter consultation, a quote for delivery, installation, supply of agreed products e.g. child car restraint, modifications, harnesses or accessories will accompany the consultation invoice .

7. Products are not supplied, d eliver ed or install ed until pa yment has been received for product and any consultations.

8. A follow-up online consultation are available to ensure the product is working and being fitted properly. Consultations are conducted via Zoom and are $85 for 30min.

Online Consultation Fees

1. Kid s afe Qld services clients nationwide. Any clients living o utside of South Ea st Queensland area map can access our online services.

2. T o ensure the product you are trial ing or purchasing is suitable for your client / child, we offer a 30-minute consultation via Zoom at $85.00 per h alf hour or part thereof.

3. An invoice for consultations will be issued at completion of the appointment and payable within 14 days

5. Consultation fee/s are payable by client even if funding is not approved/ available and regardless of the quotation being accepted.

6. Following consultation, an y products requested for trial will be invoiced

7. Products are not supplied until payment has been received for product and any consultations.

8. A follow-up online consultation at the end of the trial period is recommended to ensure the product is working and being fitted properly. Consultations are conducted via Zoom and are $85 for 30min.

Trial or purchase of behavioural or postural harnesses

1 . After a consultation, p roduct s are loaned for trial at a rate of $150 per week f or one harness. Additional harnesses in the same trial are charged at $ 110 each per week.

2. If trialed products are successful, a quote/ invoice is raised for purchase.

3 . Trial p roducts remain the property of Kidsafe Qld and cannot be retained for purchase.

4. Near the end of the trial period, a follow-up 30-minute online consultation is recommended if any of the products need to be changed. A revised product quote may be necessary.

Terms and conditions

These Terms and Conditions apply to quotes / invoices supplied for consultation services by Kidsafe QLD at an agreed location.

We use the following term:

“Kidsafe QLD” means Kidsafe Queensland Inc.

“Client”, “you”, or “your” means your service / organisation or individual (parent / carer)

Quotes

Quotes are estimates based upon the products / modifications / accessories trialed by the client and or other party. Quotes are subject to change in the event of product price increases.

Quotes are only valid for 60 days from the date of issue.

Venue/location and workplace safety

All parties are required to ensure that the inspection site has been assessed as suitable for Kidsafe QLD staff to provide service (refer to Risk Assessment Policy on Kidsafe Qld website).

Code of conduct

Requires workers and providers who deliver NDIS supports to:

Respect for individual rights to freedom of expression, self-determination, and decision-making in accordance with relevant laws and conventions.
Respect the privacy of people with disability.
Provide support and services in a safe and competent manner with care and skill
Act with integrity, honesty, and transparency
Promptly take steps to raise and act on concerns about matters that might have an impact on the quality and safety of supports provided to people with disability
Take all reasonable steps to prevent and respond to all forms of violence, exploitation, neglect, and abuse of people with disability
Take all reasonable steps to prevent and respond to sexual misconduct.

Product availability

Kidsafe Qld does not stock large quantities of products. Due to global shipping delays, expect extended delivery times for any product not in stock.

Completion of service agreement

The service agreement will cease once all approved products have been supplied and installed by Kidsafe Qld, or Kidsafe Qld has been notified by parties involved they no longer wish to proceed. At this stage any applicable consultation fee/s must be paid in full.

Re-trial / 2nd consultations:

Fees for subsequent consultations are applicable as per our service agreement.

Cancellation policy

At our discretion we may invoice for any work or expenses if any consultation is cancelled within 12 hours of the confirmed date and time of the booked service or not attended.

Product/ service satisfaction

If you or the client have any concerns regarding a service or product provided by Kidsafe Qld please contact Kidsafe Qld directly on 3854 1829 or email mobility@kidsafeqld.com.au

Product warranties will apply and it is the client’s responsibility to ensure warranty terms and conditions have been met. Kidsafe Qld is not responsible for any product/s that are damaged due to misuse and the warranty is voided.

Alternatively, contact National Disability Insurance Scheme Quality and Safeguards Commission www.ndiscommission.gov.au/about/complaints

Confidentiality

It is agreed that employees of Kidsafe QLD shall not at any time either during the consultation or thereafter, divulge any confidential information about the client to anyone whatsoever without the client’s consent in writing.

Trial products

Policies and procedures are enforced to ensure the security of our equipment. By agreeing to borrow Kidsafe Qld equipment and products, you agree to follow the procedures, terms and conditions.

1) The customer will accept full responsibility of the trial equipment for any damage, loss or disfigurement sustained while in your possession.

2) The customer accepts that the costs of any required repairs or replacement for the equipment will be borne solely by the customer.

3) The customer is deemed to be in possession of the product from the point in which they receive the equipment. The equipment will be deemed to have been returned when the equipment has been safely returned to the Kidsafe Qld premises.

4) The customer is responsible for the return of the equipment by the agreed due date. A late fee will be charged on a daily basis for any late returns. Merely shipping out the equipment before the due date is not sufficient, the equipment is deemed to be returned once it has arrived at the Kidsafe Qld premises.

5) The trial equipment must be returned in full. Any partial return or return missing components will not be accepted. The equipment will not be deemed to have been returned till all the components have also been returned. If the customer is unable to locate any components, then you will be charged for the appropriate replacement costs.

6) All loans and trials must be approved by one of our sales staff.

7) Extensions for the duration of the equipment trial may only be extended if authorised by our sales staff.

8) The trial equipment cannot be used in any manner that goes against the agreed purpose. If the customer wishes to use the trial equipment for a different purpose, then authorisation from one of our sales staff is required. Any use outside the agreed purpose may result in the customer having to return the loaned equipment earlier than agreed on and incurring a fee.

9) Any misuse, damage or loss of the equipment may result in Kidsafe Qld denying any further loans or trials to the applicable customer.

10) The customer accepts that Kidsafe Qld can demand the equipment to be returned early if there is suspicion of any misuse or damage to the borrowed equipment.

Do you accept the above terms and conditions? *

IN THE SIGNATURE PANEL BELOW YOU CAN SELECT:
'DRAW SIGNATURE' to use your finger to write your signature on a mobile device (phone or tablet)
'TYPE SIGNATURE' - to use your keyboard to write your signature (phone, tablet or desktop)

Signature *

Draw signature|Type signatureClear

By signing you agree that you have read and understood Kidsafe Qld's terms and conditions and service agreement.

We will be in touch with you as soon as possible