Total Mobility Assessment

Total Mobility Assessment

This form does not guarantee of Acceptance for a Total Mobility card. Please ensure all questions are answered.
Date of Application

MonthDayYear
Date
Name of TM Client*

First NameLast Name
Address*

Street Address

Street Address Line 2

City

Post Code
Email*
example@example.com
Phone Number*

Area CodePhone Number
Date of birth*

DayMonthYear
Date
Has the applicant previously used the Total Mobility scheme in any region?*
Private and health information is being collected to determine their eligibility for the Total Mobility scheme
The information will be stored for the duration of the client's membership of the Total Mobility scheme
The client has access to their own information and may ask for it to be corrected
What is the Primary cause of the applicant's impairment?Please select the one answer that is most applicable*

Congenital (since birth)Due to an accidentDegenerativeDue to other disease or illnessMultiple
Please select all that apply regarding your ability to use public transport. The more detail you can share, the better we can understand your needs and assess your eligibility for the Total Mobility scheme*

PhysicalMobilityPhysical otherSensoryHearingSeeingSensory otherIntellectualFragile XDown SyndromePrader Willi SyndromeDyslexiaIntellectual / learning otherMental healthAnxietySchizophreniaMental health otherNeurologicalEpilepsyDementiaStrokeMultiple SclerosisParkinson’sNeurological other
Eligibility Length*

PermanentTemporary -With temporary disability we need assurance that it will last six months or longer.
Get to or from the nearest public transport stop or station without assistance*
Stand and wait without assistance for public transport (where there is no seat).*
Get on or off public transport without assistance.*
Handle money or tickets without assistance*
Travel securely on public transport without assistance...*
Travel on public transport without getting confused or anxious*
Does the applicant use any of the following mobility aids? Please answer all
Manual Wheelchair*

YesNoSometimes
Electric Wheelchair*

YesNoSometimes
Scooter*

YesNoSometimes
Walking Frame*

YesNoSometimes
Walking Stick*

YesNoSometimes
Guide Dog*

YesNoSometimes
Travel Buddy*

YesNoSometimes
Crutches*

YesNoSometimes
Please supply further information to support this application.*
Does the applicant require the use of a wheelchair accessible vehicle to travel?*
Is the applicant in full time dependant care funded by the Government Health System?*
Transport Related Financial Assistance Details If Applicable e.g. ACC, Work and Income*
Please state where you will use your TM Card. e.g Hospital visit, shopping, family visits.etc and How often you will use it. (e.g doctors 2 x a week, shopping 4 x a month) Check link below to ensure you are not eligible for National Travel Assistance (info.health.nz)*
Please upload a recent clear head and shoulders photo of yourself. This can be taken with your phone. Please do not upload your drivers or passport photo as this will not be accepted.*

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Pay via credit/debit card. Your form will be processed within 48 hours.*

Assessment Service FeeThis fee includes credit card fee

$72.50NZD Quantity

Total

$0.00NZD

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

If Paying by Direct Credit, please use the following details:

Communicare CMA

ASB 12-3048-0279446-00

Please put surname as reference
Upload proof of online payment, if direct credit.

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Thank you for submitting your assessment form. We will be in touch soon.
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