FUNCTIONAL CAPACITY ASSESSMENT

Functional Capacity Assessment (FCA) – NDIS Participant online referral form

Functional Capacity Assessment for NDIS participants ensure that they have the right level of support and funding to achieve their goals

TPM conducts person centred and comprehensive NDIS Functional Capacity Assessment services. These are provided by an Occupational Therapist at the request of the participant, family member, advocate, Local Area Coordinator (LAC) or other involved party.
Person making referral and contact information
Participant Name*
Email*
Phone Number*
Date of Birth (YYYY-MM-DD)*
Home Address*
NDIS Participant Number*
Participant representative
NDIS participant requires support for their

Psychosocial DisabilityPhysical DisabilityIntellectual DisabilitySensory differenceNeurological needsCognitive impairment
Diagnosis and background Information
Why do you require a FCA?

NDIS Plan Review – The participant's plan is coming to an end, and they need a FCA as supporting evidence for their NDIS review.Due to a change of circumstance – The participant's functional ability has changed, and they need a FCA to show the increased need for NDIS support, services, and the level of funding required.Due to a change of circumstance – Insufficient funding within current NDIS plan – Requires a FCA as evidence to demonstrate an increased level of support and funding.I have been recommended to have a Functional Capacity Assessment
NDIS Plan goals
Service Location
NDIS Plan Start Date (YYYY-MM-DD)*
NDIS Plan End Date (YYYY-MM-DD)*
Coordinator of Supports (COS) details
NDIS Plan Management

NDIA-ManagedSelf-ManagedPlan Managed
Plan Managed details
Type a question

Type option 1Type option 2Type option 3Type option 4
At TPM, we pride ourselves on providing the highest quality level of service. The scheduled time required to complete a Functional Capacity Assessment is 15+ hours, this includes direct and indirect service provision.
I confirm that I have up to 20 hours Capacity Building (CB) funding for my FCA.I confirm that I have Core funding which I can access as my CB funding has been exhausted.I do not have any current funding for this service, however, wish to place a referral for when funding is available.I do not have any current funding for this service, however, I am paying privately for this service
Additional information

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