NDIS Online Registration Form Please complete the NDIS form below. Step 1 of 520%To assist us with your application, please complete the form below. If you need assistance completing the form, click here here to contact us.NDIS Participant DetailsTitle*MrMissMsMrsDrName* First Last Preferred NameGenderMaleFemaleOtherDate of Birth (dd/mm/yyyy)* Date Format: DD slash MM slash YYYY NDIS No*Please provide your 9-digit NDIS number.Primary Contact No*eg. 0733445566, 0400111222 (10-digits)Secondary Contact No (Optional)Email Please provide an email address so we can send our easy-read NDIS guide (requirement for all NDIS clients) - if hardcopy is preferred, let us know e.g. "Hardcopy please"Participant's Home Address* Building Name / Unit No. / Street No. Address Suburb State Postcode Appointment PreferencesIs this the address where consultations should be conducted?*Yes for in-person appointmentsNo, at alternative address.I am ok with tele-therapy (via phone) or online consultation (via Internet)In-person at Medsana Medical Clinic - Ground Floor, Building 10, Freeway Office Park, 2728 Logan Rd, Eight Mile PlainsPreferred Method Phone Video UnsureAlternative Appointment Address* Building Name / Unit No. / Street No. Address Suburb State Postcode Appointment requirements/preferences:(e.g. preferred time*, must have interpreter / carer, gender of therapist, etc.) *Note: As we travel all around Brisbane, your flexibility with time will help us avoid any travel-related charges or keep it to an absolute minimum.Times to AVOID for Appointments*(Considerations for school, day service, work, other regular appointments, certain people being present, etc. | eg. "Fri afternoons" or "25 June - hospital procedure".)List block-out times below. Click (+) to add more. Max. 5. Alternative Contacts (for appt booking)Alternative Contact NameRelationship to ParticipantAlternative Contact Phone No.Alternative Contact Email Do you have an NDIS Support Coordinator?NoYesNDIS Coordinator Contact NameNDIS Coordinator Phone No.NDIS Coordinator Email Appointment Booking ContactPreferred contact for appointment booking* NDIS Participant Alternative Contact NDIS Support Coordinator OtherPreferred Contact's Name*Preferred Contact's Phone No.*Preferred Contact's Email Who should we send reports to? (multiple options allowed)* NDIS Participant Alternative Contact NDIS Support Coordinator Other (e.g. Plan nominee) Please provide details belowDetails of person we should send reports to (name & email address / postal address)Funding Management OptionFund Management Option*NDIA ManagedPlan ManagedSelf ManagedName of Plan Manager*Email Address for Invoices* NDIS Plan & GoalsStart Date*[dd/mm/yyyy] Date Format: DD slash MM slash YYYY End Date*[dd/mm/yyyy] Please check end date is correct (especially month and year) to help us forecast plan reviews Date Format: DD slash MM slash YYYY Please describe your NDIS goals below or upload an attachment.Upload Your Documents Drop files here or Accepted file types: jpg, jpeg, png, pdf, doc, docx, xls, xlsx.Max. 5 files. Up to 10MB per file.NDIS access diagnosis(es) relating to the participant’s disability:Select TherapiesDisciplines listed alphabetically. Psychology assessments and therapy assist (incl. soft tissue therapy) options included.DIETETICS Initial Assessment for specific Dietetics Needs & Report Nutritious Food Preparation Training Other Not SurePlease describe what other Dietetics services you require:EXERCISE PHYSIOLOGY Initial Assessment for specific Exercise Physiology Needs & Report Ongoing Exercise Physiology Other Not SurePlease describe what other Exercise Physiology services you require:OCCUPATIONAL THERAPY Functional Capacity Assessment* & Report Functional Capacity Assessment* & Report to increase funding Functional Capacity Assessment* & Report for SIL/SDA Application Functional Capacity Assessment* & Report to ascertain Therapy Needs Functional Capacity Assessment* & Report for OT Needs Assistive Technology Prescription Ongoing OT Other Not Sure*FCA for participant with principal psychosocial disability may benefit from having psychologist input (option available below)Please note: My Rehab Team does NOT do complex home modifications. For a definition of complex home modifications, please refer to the NDIS website (http://bit.ly/NDIS-home-mods).Please describe what other OT services you require:PHYSIOTHERAPY Initial Assessment for Physiotherapy Needs (incl. continence) & Report Ongoing Physiotherapy Assessment for Soft Tissue Management* Other Not Sure* Note: Soft Tissue Therapy is executed by our therapy assistants (TAs) who have had additional training in this therapy, under the guidance of our registered practitioners. See below for more information about TAs.Please describe what other Physiotherapy services you require:PODIATRY Initial Assessment for specific Podiatry Needs & Report Ongoing Podiatry Orthotics Other Not SurePlease describe what other Podiatry services you require:PSYCHOLOGY ASSESSMENT Psychological assessment for diagnosis or recommendation for psychological therapy needs Psychosocial FCA (if last FCA was less than 12 months ago) Psychosocial FCA for evaluating support needs Psychosocial FCA to increase funding (includes SIL/SDA related requests) Other Not SureA participant with a principal psychosocial disability may be more suited to have their functional capacity assessment (FCA) done by a Psychologist rather than an Occupational Therapist. Please note our psychology service is for assessment only.Please add details you think are relevant for a psychological assessment:Is the participant receiving current psychological/related interventions? Yes No UnsureSPEECH PATHOLOGY Initial Assessment for specific Speech Pathology Needs & Report AAC Assistive Technology Prescription Ongoing Speech Pathology Other Not SurePlease describe what other Speech Pathology services you require:THERAPY ASSISTANT* Note: Therapy Assistants are indemnified by their supervising therapists so they only execute therapy programs prescribed by a registered therapist from My Rehab Team. Therapy Assistant for physical exercises Therapy Assistant for soft tissue management Therapy Assistant for speech pathology OtherPlease describe what other Therapy Assistant services you require:Why do you think participant needs the above assessments?(E.g. improve communication, falls risk, etc.)Is this an urgent request requiring an initial consultation within 1-2 weeks?*YesNoUnsureWhen do you need a post-assessment report to be completed by (if applicable) Date Format: DD slash MM slash YYYY Form Completion DetailsName Of Person Completing Form* First Last Today's Referral Date: 22/09/2021Contact No*Email* Do you need a quotation?NoYesAny other comments?eg. Work health & safety, home environment, etc.How will the service agreement (SA) be consented?*The info in this form will be used to generate a service agreement that we require to undertake therapy provision.Participant / nominee will sign SA document during the initial assessmentParticipant / nominee sign SA document electronically or provide consent via emailReferring NDIS support coordinator or referrer will obtain signature from the participant / nomineeUnsureIs Public Guardian consent required? Yes NoWe will expedite the initial Service Agreement if so, as it can take time to obtain Guardian consent. We cannot proceed with 1st appt without consent.EmailThis field is for validation purposes and should be left unchanged. Search for: Call 1300 469 734Fax: 07 3056 3264Make a BookingRefer Non-NDIS ClientRefer NDIS ClientNote: NDIS Referral Form is suitable all NDIS participants regardless of how their funds are managed (NDIS, Plan, or Self-managed).
