Client Details

First Name *

Last Name *

Date of Birth *

Client Phone Number *

Client Email Address *

Street Address *

City *

State *

Postcode *

Client Representative Details (Parent/Guardian/Support Coordinator/LAC)

First Name

Last Name

Organisation Name

Phone Number

Email

Street Address

City

State

Postcode

NDIS Details

Plan Management Option *

Plan Managed Self Managed Agency Managed

Plan Manager Name (If Applicable)

Plan Manager Agency (If Applicable)

NDIS Number *

Available/Remaing Funding for Capacity Building Supports

Plan Start Date

Plan End Date

Client Goals (As stated in the NDIS plan)

DISABILITY AND HEALTH INFORMATION

Primary and/or Secondary Disability *

Are there any disability or health related risk factors that our staff need to be made aware of? *

High falls riskUnaddressed incontinenceAbsence of hygiene supportsNot yet engaged with support services (e.g. no support workers)PPE required when visiting? Other (any other potential risk factors, please describe below under "Are there any issues our visiting staff should be aware of?")No risks involved

Select the type of therapy required *

Occupational TherapySpeech TherapyPsychology

Please tick the services required *

Functional Capacity AssessmentOngoing Therapeutic SupportsAssistive Technology AssessmentOT Home Modification AssessmentOT Housing Assessment (SIL, SDA, ILO)Speech & Language AssessmentPsychology Assessment (Cognitive, ASD, ADHD)

Consultation Preference *

Home visits To visit our office in Hadfield Telehealth (online)

Total Support Hours Requested *

For ongoing therapy services, please select your preferred frequency

Home Risk Assessment

Do you consent to home visits? *

What type of dwelling do you live in? (house, flat, unit, facility, caravan park, other) *

Are there any issues our visiting staff should be aware of? *

Do you have room inside your home for visiting staff to conduct the meeting/appointment? *

How many people live at your house? *

Do you, or anyone that may be present, have a history of concerning behaviours, drug and/or alcohol issues, or physical/verbal violence and aggression towards others? *

Do you have any weapons or firearms at home? *

Do you, or anyone that may be present, have any infectious diseases? *

Are there any animals on your property? If yes, what are they? *

Are there any concerns with neighbouring properties? *

Do you have phone/internet reception in your home? *

How did you hear about us? *

Please upload a copy of your NDIS plan, NDIS goals and/or any other relevant documents such as reports from other health professionals

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