Welcome to Core OT - we provide most professional service
First name
Last name
Mobile
E-mail
Date of Birth
Gender MaleFemale
Address
City
State
Participant's NDIS Number
NDIS Plan Start Date
NDIS Plan End Date
Emergency contact name
Relationship to the participant MotherFatherBrotherSisterOther
Emergency contact number
Emergency contact Email
Support Coordinator
Support Coordinator Phone
Support Coordinator Email
Plan Manager
Plan Manager Phone
Plan Manager Email
Disability/Diagnosis
Primary Disability
Secondary Disability
Other
NDIA ManagedPlan managedSelf-Managed
Functional Assessment: (Time required - approx. 12 hours)Assistive Technology Assessment:(Time required – approx. 12 hours )Assistive Technology Assessment,Trials and application (Mid- cost AT):(Time required – approx. 7-8 hours)Home Modifications assessment:(Time required – approx. 12-15 hours )Pre-Planning or Progress Assessment:(Time required - approx. 5-6 hours )NDIS- The Early Childhood Provider Form:(Time Required- approx. 2 hours (if the client is ongoing) and approx. 5-6 hours (If new referral))Housing Assessment – SDA:(Time required –approx. 20 hours)Housing Assessment – SIL:(Time required - approx. 20 hours)Combined SDA and SIL:(Time required - approx. 25 hours )
Details of Support
Additional Information
Risk of injury or death to the person or othersHomelessnessSubstance abuseLoss of placement (i.e. school, accommodation, day service)School or Service placement interruption (temporary)Police/Criminal justice contactSexualOthers (please describe below)None of the above
Physical aggressionVerbal outburstProperty damageSelf-injurious behaviorOther (please describe below)None of the above
Other potential risks or behavior of concern
LowMediumHigh
Treatment Control Measures
Responsibility
Review (re-assessment)
