OCCUPATIONAL THERAPY HOME ASSESSMENT REPORT

OCCUPATIONAL THERAPY HOME ASSESSMENT REPORT
PART 1 - Participant Details

PART 1 - Participant Details*

	Details	Further Info
Name of Participant
Date of Birth
NDIS Number
Referred By
Date of Assessment
Date of Report
Report by

Part 2 - Assessment
2.1 Background General:
Describe participant’s relevant history and current status.
2.2 Participant Goals
If the participant’s NDIS plan has been made available, you can refer to the statement of participant’s goals and outline those relevant to the AT solution.
2.3 Functional Assessment
2.3.1 Frequency of use of proposed modification.
2.3.2 Is the Participant / Nominee in agreement with this AT request? Please describe.

2.3.3 Findings from Functional Assessment - GENERAL FUNCTION

	Current Status
Mobility
Transfers
Upper limb / hand function
Lifting / carrying
Functional cognition
General safety

2.3.3 Findings from Functional Assessment - PERSONAL ADL

	Current Status
Toileting
Dressing
Showering
Grooming
Meal Preparation
Laundry

2.3.3 Findings from Functional Assessment - COMMUNITY ACCESS

	Current Status
Recreation/Leisure
Transport

PART 3 - Property Details
3.1.1 Please indicate the ownership status of the property being assessed.
Where ownership is other than the participant, provide more details, e.g. name of real estate agency and contact number.
3.1.2 Has the property had previous modifications funded by the NDIA?
If ‘yes’, please outline previous modifications completed
3.2 Structure of property
3.3 Description of property
3.4 Special Condition
PART 4 - Social Situation
4.1 Social Circumstances
Detail the participant’s living arrangements, social background, relationship status and other information relevant to the need for home modifications.
PART 5 - Complex Home Modification Recommendations
5.1 Modification Details
5.2 Externals
5.2.1 Front Access
5.2.2 Other Access
5.3 Internals
5.3.1 Bedroom
5.3.2 Living Area
5.3.3 Hallway
5.3.4 Bathroom/Toilet
5.3.5 Kitchen
5.3.6 Laundry
PART 6 - Complex Home Modification Quotes
Information from relevant builders, building project management meetings or relevant scopeof works documents.
PART 7 - Details of Assessor
Name

First NameLast Name
Work Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
DECLARATION

1. I certify that I meet the NDIA expectations of AT assessor suitability (including understanding of the current NDIS Act, Rules and Operational Guidelines) to assess the complex home modification supports at the level of complexity required by this participant.

2. I will provide appropriate evidence to the NDIA and/or Quality and Safe Guards Commission if and as requested.

3. I understand and acknowledge that the NDIA and participant will rely on my professional advice to select, source and implement this assistive technology.
Signature

Clear
Email of Assessor
example@example.com
Date

DayMonthYear
Date
Qualification: Occupational Therapist
APHRA Registration blank
About the Practitioner
Wonderland Community Services Pty Ltd: NDIS Reg: 4050042146

Trading as Wonderland Professionals

100 Pioneer Drive

Mole Creek TAS 7304

Review by Building Construction Professional (if required)

	Information
Name
NDIS Provider Registration and/or Builder Registration
Phone
Qualification

Signature

Clear
Email of Building Construction Professional
example@example.com
Date

DayMonthYear
Date
Email of Wonderland Professionals Coordinator
example@example.com
Should be Empty:

OCCUPATIONAL THERAPY HOME ASSESSMENT REPORT

PART 1 - Participant Details

Part 2 - Assessment

PART 3 - Property Details

PART 4 - Social Situation

PART 5 - Complex Home Modification Recommendations

PART 6 - Complex Home Modification Quotes

PART 7 - Details of Assessor