Section 1 — Applicant Details
Can be completed by the applicant, parent, representative or health professional.
Personal details
Full name
Date of birth
Name of parent / guardian / carer / representative
Phone
NDIS number (if known)
Section 2 — Impairment Details
Must be completed by a treating doctor or specialist.
Health professional completing this section
Full name of health professional
Professional qualifications
Address
Phone
Email
Signature
Date
2. Details of the person's impairment/s
2.1 Primary impairment (most impact on daily life)
2.2 How long has the person had this impairment?
2.3 Is the impairment likely to be lifelong?
2.4 Brief description of relevant treatment
2.5 Another impairment with significant impact?
2.6 How long has the person had this impairment?
2.7 Is the impairment likely to be lifelong?
2.8 Brief description of relevant treatment
2.9 Any other impairments?
Early intervention supports
Alleviate the impact on functional capacity
Prevent deterioration of functional capacity
Improve functional capacity
Strengthen the sustainability of available/existing supports
Details of recommended early intervention supports
3. Assessments undertaken
Care and Need Scale (CANS) — Date completed
CANS — Score or rating
CANS assessment attached? YesNo
GMFCS — Date completed
GMFCS — Score or rating
GMFCS assessment attached? YesNo
Hearing Acuity Score — Date completed
Hearing Acuity Score — Score or rating
Hearing Acuity assessment attached? YesNo
DSM-5 — Date completed
DSM-5 — Score or rating
DSM-5 assessment attached? YesNo
DSM-4 — Date completed
DSM-4 — Score or rating
DSM-4 assessment attached? YesNo
Visual Acuity Rating — Date completed
Visual Acuity Rating — Score or rating
Visual Acuity assessment attached? YesNo
CFCS — Date completed
CFCS — Score or rating
CFCS assessment attached? YesNo
Vineland-II — Date completed
Vineland-II — Score or rating
Vineland-II assessment attached? YesNo
Modified Rankin Scale (mRS) — Date completed
mRS — Score or rating
mRS assessment attached? YesNo
MACS — Date completed
MACS — Score or rating
MACS assessment attached? YesNo
ASIA/AIS — Date completed
ASIA/AIS — Score or rating
ASIA/AIS assessment attached? YesNo
Disease Steps — Date completed
Disease Steps — Score or rating
Disease Steps assessment attached? YesNo
EDSS — Date completed
EDSS — Score or rating
EDSS assessment attached? YesNo
Other — Date completed
Other — Score or rating
Other assessment attached? YesNo
Section 3 — Functional Impact
Must be completed by a health or education professional.
1. Mobility
No, does not need assistance
Yes, needs special equipment
Yes, needs assistive technology
Yes, needs home modifications
Yes, needs assistance from other persons
Describe the type of assistance required
2. Communication
No, does not need assistance
Yes, needs special equipment
Yes, needs assistive technology
Yes, needs home modifications
Yes, needs assistance from other persons
Describe the type of assistance required
3. Social Interaction
No, does not need assistance
Yes, needs special equipment
Yes, needs assistive technology
Yes, needs assistance from other persons
Describe the type of social interaction assistance required
4. Learning
No, does not need assistance
Yes, needs special equipment
Yes, needs assistive technology
Yes, needs assistance from other persons
Describe the type of assistance required
5. Self-Care
No, does not need assistance
Yes, needs special equipment
Yes, needs assistive technology
Yes, needs home modification
Yes, needs assistance from other persons
Showering / bathing
Eating / drinking
Overnight care (e.g. turning)
Toileting
Dressing
Describe the type of assistance required
6. Self-Management
No, does not need assistance
Yes, needs special equipment
Yes, needs assistive technology
Yes, needs assistance from other persons
Describe the type of assistance required
