Participant Details
Please upload any relevant diagnostic and medical documentation here.
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Address
Residence Type
Private Residence
Apartment
Group Home
Aged Care Facility
Hospital
Does the client have any communication requirements or difficulties?
*
Yes
No
Are there any restrictive practices in place?
*
Yes
No
If yes, please explain:
If yes, please explain:
Participant Representative Details
Contact to organise appointments
Participant
Family Member
Friend
Support Coordinator
Carer
Health Professional
Other
Funding Details
Plan
*
Plan-Managed
Self-Managed
Funding for Occupational Therapy is listed under the Capacity Building category in your NDIS Plan.
Referrer Details (Person Making the Referral)
I have obtained consent from the participant to make this referral and provide Above and Beyond Therapy with the participant's personal and medical details.
*
Reason For Referral
Service/s required:
*
Skill development and ongoing therapy
Functional capacity assessment
Sensory assessment
Assistive technology assessment
Letter of recommendation
Please attach a copy of the Participant's current NDIS plan and Goals
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Risk Assessment for Home/Community Visits
Location of Visit
Private Residence
Day-Care
School
Group Home
Aged Care Facility
SIL
SDA
Is there any difficulties in accessing the property?
*
Yes
No
Unknown
Is there ample parking near the appointment location?
*
Yes
No
Unknown
Will I be using the front door and will someone greet me upon arrival?
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Yes
No
Unknown
Does the participant require an interpreter or have any communication needs??
*
Yes
No
Unknown
Does the participant live alone?
*
Yes
No
Unknown
Does anyone (including the participant) at the location have any behaviours of concern or risk?
*
Yes
No
Unknown
Are there any pets or animals at the premises?
*
Yes
No
Unknown
Presence of illicit substances at premise.
*
Yes
No
Unknown
Presence of firearms at premises.
*
Yes
No
Unknown
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