NDIS Waitlist Submission Excel OT
Clients Name
*
First Name
Last Name
Client's DOB
*
Gender
*
Female/male/other
Client's School/workplace and year level
*
Parent/Carer Name #1
*
First Name
Last Name
Parent/Carer Name #2
First Name
Last Name
Do any other family members currently or have previously accessed OT with Excel?
*
Please provide details if possible
Home address
*
Email Address
*
Phone Number
*
Cultural and ethnic background
Does the client/family identify as Aboriginal or Torres Strait Islander?
Does the client/family require an interpreter to access services? If yes, please provide further details.
Are there any religious or cultural practices your family observes that you would like us to know about?
Who is completing this form?
*
Including relationship to client
Contact number of person completing this form.
*
How will the client be funding services?
*
Please Select
NDIS
Private Health Fund
Privately paying
Medicare Plan (CDM/EPC)
Do you have NDIS Funding?
*
Please Select
Yes
No
NDIS Participant Number
How is your NDIS plan managed?
Self managed
Plan managed
If plan managed who is your plan manager?
NDIS plan dates
Goals for Therapy
What service do you require?
*
Ongoing therapy to support skill development
Assessment (Eg. Functional Capacity Assessment, Sensory Assessment, Handwriting Assessment)
Please comment on the type of assessment you require if known
Do you have a preference for your child's OT sessions to be school visits? Be advised this cannot be guaranteed and is subject to OT availability & suitability of sessions out of clinic.
If you could pick three things to work on in OT, what would they be?
*
Child's Medical History
Diagnosis
*
Any relevant medical history/allergies
Custody/Guardianship
Child lives with
*
Please Select
Both parents
Shared custody
Parent 1
Parent 2
Other
If other, please specify
Is a parenting or restraint order applicable? Eg. Guardianship
Please list any other special family circumstances of which Excel OT should be aware of to provide maximum support.
Please provide the names and contact details of other adults who may be involved in therapy.
For example, grandparents or support workers dropping client off to therapy sessions
Date form completed
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Day
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Month
Year
Date
Submit
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