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Participant's Details

Is the participant over 18?

Yes No Invalid Input

Sorry, a participant must be over 18 for us to work with them.

First Name of Participant*

What is the First Name of the Participant?

Telephone of Participant

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NDIS Participant Number if Applicable

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Last Name of Participant*

What is the Last Name of the Participant?

Particpant's Email

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Date of Birth*

Please let us know the client's Date of Birth

Street Address*

Please let us know the Street Address of the participant.

City*

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State*

Please let us know what state the participant lives in

Postcode*

Please let us know the clients Postcode

Living Arrangement (with Family, Alone, etc..)*

please let us know the participants living arrangement

NDIS Plan Start Date:*

please let us know the NDIS Plan start date

NDIS Plan End Date:*

please let us know the NDIS Plan end date

List of Disabilities*

please provide a list of disabilities that the participant has

Do they have other conditions?*

Yes No

please let us know if they have other medical history?

Other Conditions

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Support Person

First Name*

What is the support persons first name?

Phone Number*

What is the support person's phone number?

Last Name*

Please let us the support persons Last Name

Please enter a valid Email Address

Is the support person living with the participant*

Yes No

please let us know if the Support person is living with the Participant

NDIS Coordinator

Are you a recurring NDIS Coordinator? then create an account with us and prefill some fields on your next submissions.

NDIS Coordinator Name

Please let us your First Name

Phone Number

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Please enter a valid Email Address

Preferred Contact

Please contact the...*

Participant Support Person Support Coordinator

Please let us know the preferred contact

NDIS Funding Type

The NDIS funding type is...*

Self-Managed NDIA Managed Plan Managed

please let us know the funding type

Plan Manager Organisation/Name*

Please let us know the Managers Name

Plan Manager's Email*

please let us know the Plan Manager's Email

Please confirm there is funding in the: Improved Daily Living (CB Daily Activity). An initial OT assessment, travel and identification of therapy/functional needs will take 5 hours. Please contact Propel Occupational Therapy for quotes for different services available (see list below).*

Yes (5 Hours minimum required)
Unsure / No. Please Contact us before booking

please let us know if there is funding in the sections above

Current NDIS Provider (Name/Type)

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To assist us with ensuring we allocate the most suitable Occupational Therapist for participant, please provide reason for Occupational Therapy Assessment (tick all that apply).*

Skill building (e.g moving out of home, cooking, money skills, travel training, personal care skills)
Assistive Technology – low cost/low risk (e.g. shower chair, toilet seats, adapted kitchen aids).
Assistive Technology requiring prior approval from NDIS (high cost/high risk) e.g. scripted wheelchairs, shower commodes, bed, pressure cushions) . These items involve equipment trials, quotes and OT reports to NDIS.
Comprehensive Functional Assessment and Report (Care needs assessment)
Supported Independent Living / Specialist Disability Accommodation Assessment and Report.
Short Term Accommodation
Unsure
Other

please provide reason for Occupational Therapy Assessment

Other

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Other Information

How Did You Hear About Us?*

please let us know how you found out about us

Other

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Name of Person Completing Form*

please let us know the name of the person completing this form

Confirm Email for Person Completing Form*

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Please Attach NDIS PLAN or Goal Sections of NDIS Plan*

Please Attach NDIS PLAN or Goal Sections of NDIS Plan

Make a Booking

Please use this form to make a referral

Referral (Make a Booking)

Other Information

Contact Details

Townsville

Cairns

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Referral (Make a Booking)

Other Information

Contact Details

Townsville

Cairns

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