MDSS Occupational Therapy Intake Form

Occupational Therapy Intake Form
Please note: MDSS Occupational Therapy currently only accepts referrals for clients accessing services through the NDIS or Home Care Packages. At this time, we are unable to accept private clients or referrals outside of these. If you have any questions or concerns, please do not hesitate to get in touch.
Which service(s) are you seeking?
Client Name
Date of Birth

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
Address
Phone number
Email Address
example@example.com
Occupation - if none type NA
Preferred Method of Contact
Emergency Contact:
Name
Relationship
Phone number
Reference Number eg NDIS number etc
Is the client Plan Managed or Self-Managed?
Please provide Plan Manager Name and Email address if applicable
Support Coordinator Name and Email address if applicable
Funding Source
For NDIS or Home Care Package, what is your Support Coordinator name and contact details:
What type of service are you requiring?

Other
What specific funding is allocated to these services?
Please Provide NDIS Plan Dates If Applicable
The Functional Capacity Assessment requires a number of self-assessment tools to be completed. Are you able to complete these yourself, or would you prefer to have support?
Please upload a copy of the NDIS plan if appropriate

Cancelof
Referral Information

Other
Primary Diagnosis/Reason for Referral
If ticked one of the above, please provide more details:
Please upload any relevant medical or allied health reports (paediatrician, psychologist, previous occupational therapy assessments, speech pathology)

Cancelof
Allergies? If none, type NA.
Will a support worker attend the sessions?

Other
Support Worker organisation details
If this is a self referral, I give permission Aus Disability Support to share relevant reports, information and updates with:
NDIS Goal Alignment - Participant Goals from NDIS Plan. Please list. If not NDIS please type NA
Where are the sessions to be held if not at the Occupational Therapy Office?
If self referral, I consent to Aus Disability Support Pty Ltd collecting and storing my personal and medical information for the purpose of providing allied health services. I understand my information will be kept confidential and only shared with relevant professionals involved in my care as required.
Signature of person completing the form
Name of person completing the form
Relationship to client - if self, type NA
Date

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
Should be Empty: