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 risk
Unaddressed incontinence
Absence of hygiene supports
Not 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
Type of therapy required
*
Occupational Therapy
Speech Therapy
Physiotherapy
Psychology
Please tick the services required
*
Functional Capacity Assessment
Ongoing Therapeutic Supports
Assistive Technology Assessment
OT Home Modification Assessment
OT Housing Assessment (SIL, SDA, ILO)
Speech & Language Assessment
Psychology Assessment (Cognitive, ASD, ADHD)
Consultation Preference
*
Home visits
To visit our office in Hadfield
Telehealth (online)
Total Support Hours Requested
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1-10 Hours
10-20 Hours
20-30 Hours
30+ Hours
For ongoing therapy services, please select your preferred frequency
Weekly
Fortnightly
Monthly
Home Risk Assessment
Do you consent to home visits?
*
YES
NO
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?
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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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