It is a requirement that this information is filled out prior to therapy commencement. Our clinicians must be aware of this information to ensure they are best matching the therapeutic goals with what the client needs, and also to keep the administration process running smoothly. Participant Name DOB Phone Email NDIS Number NDIS Plan Start Date NDIS Plan End Date Plan Nominee Details (if not/ different to participant) Name Relationship Phone Email NDIS Contact NDIS Contact Contact Name Phone Email Support Coordinator Details (if applicable) Name Company Phone Email Plan Management Please Select ---Self-ManagedPlan-Managed Company Plan Manager Email Phone Goals Official Diagnosis / Diagnoses Disabilities (if unsure, please contact NDIS Support Coordinator) Primary Secondary Assessment Needed or Suspected Diagnosis Requiring Assessment (if applicable) Allocated Funding Description Improved Daily Living Funds. Psychology – Assessment, Recommendation, Therapy and/or Training Item Reference Number 15_056_0128_1_3 Item Cost (hourly) OT $193.99 Number of Hours Total Allocated Funding $ Please specify exactly what this allocated funding covers. Is the total allocated funding including or excluding the cost for assessment and report writing? Please only include remaining funding. Planned Review Date Unplanned Review (please select if it is known that participant will have an unplanned review) Report Due Date
