Wise Occupational Therapy intake form

1
Is this referral for you, or for another person?* This field is required.'another person' can mean a family member, a client, a patient etc
MeAnother person
2
Please note:

If you are filling this form on behalf of an NDIS participant who is over 18 years old, you and the client will need to complete an "Authority to act as an advocate form" together to allow you to speak on behalf of the client. A link to the Authority to act as an advocate form will be sent to your email following completion of this form.
3
Before beginning please note:

This form can be saved at any point and continued later

Some questions may load slowly, please be patient if the form takes some time to load.

What you'll need for this form:

NDIS plan/funding details

NDIS plan approval letter & NDIS goals

Contact information for any alternative contacts, support coordinators, health professionals, plan management companies etc.,

Any relevant documents/records that you'd like our OT's to read to get a better understanding of your disability needs,

A rough idea of what services you're seeking

An understanding of what 'disability advocacy is' which can be found at the end of the form.
4
What is {their}{your} name?* This field is required.
First Name
Last Name
5
What is {your}{participantName:first}{possessiveApostrophe} date of birth?* This field is required.
Date
Day
Month
Year
6
In terms of gender, how {doesLc}{doLc} {you}{participantName:first} identify?* This field is required.
Female
Male
Non-binary
Prefer not to say
Other
7
What are {your}{participantName:first}{possessiveApostrophe} preferred pronouns?* This field is required.
She / her / hers
He / him / his
They / them / theirs
Other
8
Is there anything you would like us to know about {you}{participantName:first}? e.g, {your}{their} culture, diversity, values, beliefs, or background.* This field is required.
9
What is {your}{participantName:first}{possessiveApostrophe} address?* This field is required.
Address
(Optional) Address line 2
Suburb/city
NSW
Please Select
NSW
VIC
QLD
SA
NT
ACT
WA
TAS
State
Post code
10
To arrange appointments, is it best to contact you, or an alternative contact person? Who would you prefer us to contact first?That is, would you prefer us to contact you or someone else (instead of you), to make appointment arrangements?
It's best to contact me directly to arrange appointments.
I have an alternative contact person who arranges my appointments
11
To arrange appointments, is it best to contact you, {participantName:first}, or an alternative contact person?Who will be the person we contact first to get in touch with {participantName:first}?
It's best to contact the participant directly to arrange their appointments
The participant has an alternative contact person. Its best to contact the alternative contact person to arrange appointments.
I am both the referrer and the alternative contact person. Its best to arrange appointments by contacting me.
Other
12
If {you}{participantName:first} {have}{has} a landline, what is the phone number?
Area code
Phone number
13
If {you}{participantName:first} {have}{has} a mobile phone, what is the phone number?
Enter phone number with no spaces
14
What is {your}{participantName:first}{possessiveApostrophe} email address?
example@example.com
15
How {doLc}{doesLc} {participantName:first}{you} prefer to be contacted?* This field is required.
Phone (landline)
Phone (mobile)
Email
Don't mind
Through an alternative contact person
Other
16
Please provide us with at least one set of contact details for {you}{participantName:first}!Please provide at least one set of contact details.
Landline number
Mobile phone number
Email address
17
At what time of the day {doLc}{doesLc} {you}{participantName:first} prefer to be contacted?* This field is required.
Anytime
8:00am - 12:00pm
10:00am - 2:00pm
12:00pm - 4:00pm
2:00pm - 6:00pm
Other
18
{do}{does} {you}{participantName:first} prefer that we use an interpreter?* This field is required.
Yes
No
19
Which language (and dialect, if needed) interpreter is required?
20
Is there anything you would like us to know to help us communicate with {you}{participantName:first}?
21
Which best describes your relationship to {participantName:first}?
PersonalProfessional
22
Which best describes your relationship to {participantName:first}?That is, you are {participantName:first}{possessiveApostrophe} _____________.
Parent
Child
Sibling
Guardian
Friend
Other
23
Which best describes your relationship to {participantName:first}?That is, you are {participantName:first}{possessiveApostrophe} _____________.
Coordinator of supports (COS) (AKA support coordinator)
Occupational therapist
GP
Other
24
What is your name?(The referrer)
First name
Last name
25
Which company do you work for?
26
If you have a landline, what is the phone number?
Area code
Phone number
27
If you have a mobile phone, what is the phone number?
Enter phone number with no spaces
28
What is your email address?
example@example.com
29
Please provide us with at least one set of contact details.
Landline number
Mobile phone number
Email address
30
What is {your}{participantName:first}{possessiveApostrophe} alternative contact person's name?(That is, the person you'd prefer that we contact instead of {you}{participantName:first} or when we can't get in contact with {you}{participantName:first})
First Name
Last Name
31
What is {whatIs574:first}'s relationship to {you}{participantName:first}?That is, {whatIs574:first} is {your}{participantName:first}{possessiveApostrophe} ____________.
Parent
Child
Sibling
Guardian
Friend
Coordinator of supports
Other
32
(Optional) Which company does {whatIs574:first} work for?
33
If {whatIs574:first} has a landline, what is the phone number?
Area code
Phone number
34
If {whatIs574:first} has a mobile phone, what is the phone number?
Enter phone number with no spaces
35
What is {whatIs574:first}'s email address?
example@example.com
36
How does {whatIs574:first} prefer to be contacted?
Phone (landline)
Phone (mobile)
Email
Don't mind
Other
37
Please provide at least one set of details for us to contact {whatIs574:first}.
Landline number
Mobile phone number
Email address
38
At what time of the day does {whatIs574:first} prefer to be contacted?
Anytime
8:00am - 12:00pm
10:00am - 2:00pm
12:00pm - 4:00pm
2:00pm - 6:00pm
I don't know
Other
39
What are {your}{participantName:first}{possessiveApostrophe} disabilities or medical conditions?* This field is required.
Huge
Large
Normal
Small
Ok
Ok
40
{do}{does} {you}{participantName:first}{possessiveApostrophe} have a GP that you can provide contact details for?* This field is required.
YESNO
41
Who is {your}{participantName:first}{possessiveApostrophe} GP?(AKA general practitioner, family doctor)
Dr
Dr
Prefix/title
First name
Last name
42
What is {whoIs:prefix} {whoIs:last}'s business address?Please give as much information as you can.
Practice name (if applicable)
Street address
Suburb/town
State / Province
Post code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
43
What are {whoIs:prefix} {whoIs:last}'s contact details?Please give us as much as you can, but at least a phone number.
Phone number
Fax number
Email address
44
(Optional) If you have a GP referral letter for us, please upload it here.(It's completely fine if you don't. Some people do, some don't.)
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
45
(Optional) If you have a copy of {your}{participantName:first}{possessiveApostrophe} health summary or health history, please upload it here.(It's completely fine if you don't. Some people do, some don't.)
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
46
{do}{does} {you}{participantName:first}{possessiveApostrophe} have any of these other health professionals in {your}{their} life at the moment?* This field is required.
Occupational therapist
Physiotherapist
Speech therapist
Exercise physiologist
None
Other
47
{yourUc}{participantName:first}{possessiveApostrophe} occupational therapist (not us, obviously...)Please give as many details as you can.
What is their name?
Which company do they work for?
What is their landline phone number?
What is their mobile phone number?
What is their email address?
48
If you can, please upload the most recent report from this OT.Please upload more reports, if you think that would help us to understand where {you}{they} are at.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
49
{YourUc}{participantName:first}{possessiveApostrophe} physiotherapist...Please give as many details as you can.
What is their name?
Which company do they work for?
What is their landline phone number?
What is their mobile phone number?
What is their email address?
50
If you can, please upload the most recent report from this physiotherapist.Please upload more reports, if you think that would help us to understand where {you}{they} are at.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
51
{yourUc}{participantName:first}{possessiveApostrophe} speech therapist...Please give as many details as you can.
What is their name?
Which company do they work for?
What is their landline phone number?
What is their mobile phone number?
What is their email address?
52
If you can, please upload the most recent report from this speech therapist.Please upload more reports, if you think that would help us to understand where {you}{they} are at.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
53
{yourUc}{participantName:first}{possessiveApostrophe} exercise physiologist...Please give as many details as you can.
What is their name?
Which company do they work for?
What is their landline phone number?
What is their mobile phone number?
What is their email address?
54
If you can, please upload the most recent report from this exercise physiologist.Please upload more reports, if you think that would help us to understand where {you}{they} are at.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
55
Other health professionals...Please give as many details as you can.
What is their name?
Which company do they work for?
What is their landline phone number?
What is their mobile phone number?
What is their email address?
What is their discipline/qualification (e.g., orthoptist, psychologist, etc.)
56
If you can, please upload the most recent report from this health professional.Please upload more reports, if you think that would help us to understand where {you}{they} are at.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
57
For these OT services, {doLc}{doesLc} {you}{participantName:first} wish to use funding under any of the following schemes?* This field is required.
NDIS
Lifetime Care & Support (LTCS)
Workers Insurance
Workers Care
Not going to be using a funding scheme (that is, these services will be paid directly out of pocket)
Other
58
What is {your}{participantName:first}{possessiveApostrophe} NDIS number?
No spaces
59
What is the start date of {your}{participantName:first}{possessiveApostrophe} NDIS plan?
Date
Day
Month
Year
60
What is the end date of {your}{participantName:first}{possessiveApostrophe} NDIS plan?
Date
Day
Month
Year
61
If you have a copy of {your}{participantName:first}{possessiveApostrophe} NDIS plan, please upload it here.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
62
If you don't have a copy of {your}{participantName:first}{possessiveApostrophe} NDIS plan, please type in the goals that are on {your}{participantName:first}{possessiveApostrophe} NDIS plan.There are usually 'short-term goals' and 'medium or long-term goals'.
Huge
Large
Normal
Small
Ok
Ok
63
Please use this space for any extra information you wish to share regarding {your}{participantName:first}{possessiveApostrophe} funding (optional)E.g., any upcoming plan review dates, etc.,
Huge
Large
Normal
Small
Ok
Ok
64
{do}{does} {you}{participantName:first} have a coordinator of supports?If you're not sure, please choose 'No'.
YesNo
65
What is their name?({yourUc}{participantName:first}{possessiveApostrophe} coordinator of supports)
First Name
Last Name
66
Which company does {whatIs602:first} work for?
67
If {whichCompany182} has a landline, what is the phone number?
Area code
Phone number
68
If {whatIs602:first} has a mobile phone, what is the phone number?
Enter phone number with no spaces
69
What is {whatIs602:first}'s email address?
example@example.com
70
Please provide either a contact number or email address for {whatIs602:first}.
E.g., mobile number, landline, email address
71
Who pays the invoices for the 'Capacity-building Daily Activity' section of {your}{participantName:first}{possessiveApostrophe} NDIS plan?That is, how is this part of {your}{participantName:first}{possessiveApostrophe} NDIS plan 'managed'?
Service providers send their invoices to the participant directly. The participant then pays the invoices then later gets reimbursed by the NDIA (that is, 'self-managed').
A family member or friend pays the invoices, then gets reimbursed by the NDIA (that is, 'nominee-managed').
Service providers submit their invoices to the NDIS through the portal (that is, 'agency-managed').
Service providers send their invoices to a plan management company (that is, 'plan-managed').
Not sure
72
The plan nominee
Me (the referrer)
The alternative contact person (details given earlier in the form)
Someone else
73
The plan nominee
The alternative contact person (details given earlier in the form)
Someone else
74
Who is the family member or friend who pays invoices for {you}{participantName:first}?(That is, who is the person who manages {your}{participantName:first}{possessiveApostrophe} NDIS plan?)
First Name
Last Name
75
What is {whoIs603:first}'s relationship to {you}{participantName:first}?(That is, {whoIs603:first} is {your}{participantName:first}{possessiveApostrophe} ____________.
76
If {whoIs603:first} has a landline, what is the phone number?
Area code
Phone number
77
If {whoIs603:first} has a mobile phone, what is the phone number?
Enter phone number with no spaces
78
What is {whoIs603:first}'s email address?
example@example.com
79
Please provide at least one set of contact details for {whoIs603:first}.
Landline number
Mobile phone number
Email address
80
What is the name of {your}{participantName:first}{possessiveApostrophe} plan management company?
81
Please provide contact details for the plan management company
Contact number
Email address
82
{does}{do} {you}{participantName:first} need any of the following?* This field is required.
Equipment (assistive technology)
Home modifications
Driving assessment & rehab
Vehicle modifications
An assessment and report of their support needs
An assessment and report of their housing needs
Everything! They need everything!
Not sure
Not sure - skip services questions
Other
83
What equipment do you think {you}{participantName:first} might need?
If you're not sure, please type, 'Not sure', or just leave the box blank.
84
What home modifications do you think {you}{participantName:first} might need?
If you're not sure, please type, 'Not sure', or just leave the box blank.
85
{do}{does} {you}{participantName:first} want to START driving or GET BACK TO driving?
START drivingGET BACK TO driving
86
{does} {participantName:first} have a driver's licence?
No, they have never had a licence of any kind.
They have a learner's licence but have never driven.
They have a learner's licence and have done some driving.
They have a licence but it's been cancelled or downgraded because of their disability.
They have a licence.
I don't know.
Other
87
{do} {you} have a driver's licence?
No, I have never had a licence of any kind.
I have a learner's licence but I have never driven.
I have a learner's licence and I have done some driving.
I have a licence but it's been cancelled or downgraded because of my disability.
I have a licence.
I don't know.
Other
88
{haveUc}{hasUc} {participantName:first}{you} been told {you}{they} need to have an occupational therapy driving assessment?
Yes
No
Not sure
89
Why {doLc}{doesLc} {you}{participantName:first} need to have a driving assessment?
If you're not sure, please type, 'Not sure', or just leave the box blank.
90
(Optional) If {participantName:first}{you} {have}{has} received a letter from Transport for NSW, recommending an occupational therapy driving assessment, please upload the letter here.
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Max. file size: 10.6MB
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91
(Optional) If {your}{participantName:first}{possessiveApostrophe} doctor has completed a Transport for NSW Medical Report, please upload it here.
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Select files to upload
Max. file size: 10.6MB
Cancelof
92
(Optional) If {your}{participantName:first}{possessiveApostrophe} doctor has completed a referral letter, please upload it here.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
93
What vehicle modifications do you think {you}{participantName:first} might need?
If you're not sure, please type, 'Not sure', or just leave the box blank.
94
Would {you}{participantName:first} be a driver or a passenger?
Driver
Passenger
Both
Not sure
95
What vehicle make, model and year of production is the vehicle {you}{participantName:first} would to modify to make it accessible?
96
How many other people need to travel in the car?
97
Would you like to request a particular occupational therapist?* This field is required.
YESNO
98
Which therapist would you like to request?
99
How easy it is to find {your}{participantName:first}{possessiveApostrophe} home?* This field is required.(By the way, the next question will be about how easy it is to find parking...)
Hard to find
Easy to find
Somewhere in between easy and hard...
100
Do you have any tips for us, to help us find {your}{participantName:first}{possessiveApostrophe} home?(e.g., landmarks, which apartment building, which level in the elevator, etc.)
Huge
Large
Normal
Small
Ok
Ok
101
How easy is it to find suitable parking?* This field is required.(We usually need parking for 2-3 hours.)
Hard to find
Easy to find
Somewhere in between easy and hard...
102
Do you have any tips for us, to help us find suitable parking?(e.g., landmarks, okay to park in driveway, okay to park in front yard, visitor parking on site, council car park nearby, etc.)
Huge
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Normal
Small
Ok
Ok
103
Please describe the emergency evacuation plan for {your}{participantName:first}{posessiveApostrophe} home.* This field is required.In the event of a fire or emergency which means we must all evacute the home, where do we go? and, how {do}{does} {you}{participantName:first} get evacuated?
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Ok
Ok
104
{do}{does} {you}{participantName:first} have any pets in the home that we need to be concerned about (such as dangerous dogs)?* This field is required.
No
Yes, but they can be secured when the OT comes to visit.
Yes, and they can't be secured when the OT comes to visit.
Yes, but they are not a concern (well-behaved)
105
Do you have any thoughts about what to do with the pet/s, when we come to visit?For example: Could someone take them for a walk? Could they go to the groomer that day? Could they go on a doggie-date to a friend's house? (Remember that we might be there for 2-3 hours - sometimes longer.)
Huge
Large
Normal
Small
Ok
Ok
106
Are there any firearms on the property?* This field is required.
No
Yes, but they're secured
Yes, and they're not secured
107
Are there any people in the household with challenging behaviours that we need to be aware of?This could be {participantName:first} or another person (or other people).
Yes - The participant has some challenging behaviours.
Yes - Another person (or people) in the house has/have some challenging behaviours.
No
108
Are there any people in the household with challenging behaviours that we need to be aware of?This could be {you} or another person (or other people).
Yes - I have some challenging behaviours.
Yes - Another person (or people) in the house has/have some challenging behaviours.
No
109
Please tell us more information about {your}{participantName:first}{possessiveApostrophe} challenging behaviours.
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Normal
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Ok
Ok
110
Will this other person (or people) be at home when we come to do a home visit?
Definitely yes. (It can't be avoided.)
Definitely yes, but I need them to be home when you come to visit, because I want you to see the impact of their behaviour on the participant.
It is possible to choose a suitable time, when the other person/people won't be at home.
Definitely no.
111
Will this other person (or people) be at home when we come to do a home visit?
Definitely yes. (It can't be avoided.)
Definitely yes, but I need them to be home when you come to visit, because I want you to see the impact of their behaviour on me.
It is possible to choose a suitable time, when the other person/people won't be at home.
Definitely no.
112
Please tell us more information about the challenging behaviours of the other person or people in {your}{participantName:first}{possessiveApostrophe} household.
Huge
Large
Normal
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Ok
Ok
113
Would you like to access the Disability Advocacy sheet we have available?* This field is required.Advocacy provides assistance and support to ensure that: - Rights are upheld; - Choice and control is maintained, and people with a disability have their voice heard; - Any needs and viewpoints are presented to government, service providers and the broader community; and - Changing of policies and practices to promote fair treatment and social justice for people with a disability.
YESNO
114
Disability Advocacy fact sheet
115
Is there anything else you want us to know?
116
If there are any documents you want us to see, please upload them here.
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Max. file size: 4.9MB
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117
Do you consent and permission for Wise Occupational Therapy to collect and hold the personal information provided in this form?* This field is required.We need to be able to store this information to provide services.
Yes
118
Do you consent to Wise Consulting contacting the people in this form? * This field is required.Including the health professionals listed, alternative contact persons, plan managers, support coordinators etc...
YESNO
119
Please verify that you're not a robot.
120
Date
Date
Year
Month
Day
121
Age
122
You
123
Your
124
Have
125
Has
126
Have Uc
127
Has UC
128
Do
129
Does
130
Their
131
They
132
possessive Apostrophe
133
plural
134
Them
135
Your UC
136
do LC
137
does LC
Should be Empty: