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.
NDIS Plan Start Date
NDIS Plan End Date
Plan Nominee Details (if not/ different to participant)
Support Coordinator Details (if applicable)
Official Diagnosis / Diagnoses
Disabilities (if unsure, please contact NDIS Support Coordinator)
Assessment Needed or Suspected Diagnosis Requiring Assessment (if applicable)
Improved Daily Living Funds. Psychology – Assessment,
Recommendation, Therapy and/or Training
Item Reference Number
Item Cost (hourly)
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
(please select if it is known that participant will have an unplanned review)
Report Due Date