Pre Total Mobility Assessment

Pre Total Mobility Assessment

This form does not guarantee of Acceptance for a Total Mobility card.
Select Assessment Venue
If rest home or care facility, please state name, address, phone and Contact
Has the applicant previously used the Total Mobility scheme in any region?*
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
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
Date of birth*

DayMonthYear
Date
What is the Primary cause of the applicant's impairment *
Which of the categories best describes the general nature of the applicant's impairment(s)? Select many
Please select as many answers as applicable

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

PermanentTemporary -With temporary disability we need assurance that it will last six months or longer.
Eligibility Information Can the applicant do the following independently in a safe and dignified manner? Get to or from the nearest public transport stop or station without assistance
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
Any additional 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, Winz
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)
A photo is now required. Please upload a clear face photo for your I.D. Photographs should be head and shoulders (basically passport photos). Head to waist doesn’t provide the necessary detail when reproduced on the TM card.

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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

$62.50NZD Quantity

Rest Home AssessmentVisit to Rest Home Includes fee

$72.50NZD Quantity

Total

$0.00NZD

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

Upload proof of online payment, if direct credit.

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