OCCUPATIONAL THERAPYNDIS PARTICIPANT INTAKE FORMIf you have any questions, please feel free to contact us. Participant Information Participant Full Name * First Name Last Name Preferred Name D.O.B Age Preferred Pronoun Address Address 1 Address 2 City State/Province Zip/Postal Code Country Phone Email Guardian Information Guardian Full Name First Name Last Name Phone Email Relationship to Participant Preferred Contact for Participant * Client Guardian Other Preferred Contact Method * Text Call Email If you selected 'Other', please provide details of contact Name, relationship to client, email, phone and other information you think we would find useful. NDIS Plan Information NDIS Fund * *The Gray Area is working towards becoming a registered NDIS service provider in order to assist NDIS/ Agency managed participants. Please feel free to contact us regarding ways we can assist with your current funding application. Plan Managed Self Managed NDIA / Agency Managed NDIS Number * NDIS Plan Dates NDIS Review Date (if known) Fund Manager Name (if applicable) Fund Manager Email (if applicable) Service Type Service Location School Home Clinic Other Services Required * Assessments Intervention / Therapy If applicable, what Assessment would be relevant to you? If you are unsure of what assessment would be suitable for you, please visit our Occupational Therapy section on our website or please give us a call on 0400 225 866. Functional Capacity Assessment (FCA) Independent Living Options (ILO) Supported Independent Living (SIL) Specialist Disability Accomodations. (SDA) Main Reason * Physical Cognitive Intellectual Sensory Psychosocial / Mental Emotional Regulation Fine Motor Skills Gross Motor Skills Play Time Skills Self-Care Skills Other Other Services Engaged Please list any other services you are engaged in and the name of the practice. Further Information Thank you!
