Fields on page 2
Title (e.g. Ms, Mr, Mx)
Given name/s
Preferred name
Surname
Other name
before marriage)
Preferred gender
Preferred pronoun
□ YesNo
□ Option 1Option 2Option 3Option 4
Fields on page 3
What is your date of birth
___ /
___ / ___ /
What is your country of birth
Visa type
Nationality
Number, Street
Suburb
State
Postcode
□ Option 1Option 2Option 3Option 4Option 5
□ YesNo
□ YesNo
What type of visa do you have Option 1Option 2Option 3
Fields on page 4
address below
Suburb
State
Postcode
Family Member 1
NDIS Number
Family Member 2
NDIS Number
Family Member 3
NDIS Number
Family Member 4
NDIS Number
the address Option 1Option 2Option 3Option 4Option 5
or is already a participant YesNo
Fields on page 6
Number (CRN)
your personal and sensitive YesNo
Do you consent to the NDIA collecting your age and residence information from Centrelink using your Customer Reference Number (CRN)? Option 1Option 2Option 3
Fields on page 7
Home phone
Mobile phone – provide details below
______________________________________________
TTY – provide details below
□ Please use SMS only, I am Deaf or Hard of Hearing
□ Yes – provide language below
□ YesNo
Note: If you want us to contact your Option 1Option 2Option 3
How would you like us to contact you? Option 1Option 2Option 3Option 4Option 5Option 6Option 7Option 8Option 9
□ Option 1Option 2Option 3Option 4Option 5
Do you need an interpreter to help YesNo
Fields on page 8
First name/s
Surname
Your relationship to the applicant
Note: You will need to provide proof that Option 1Option 2Option 3
Fields on page 9
What is your date of birth
___ /
___ / ___ /
Home phone 1
□ Work phone – provide details below
□ Mobile phone – provide details below
□ Email – provide details below
□ TTY – provide details below
□ No
Do you need an interpreter to help YesNo
access request YesNo
Fields on page 10
Note: Your main disability is the one
Disability 2
Disability 3
Disability 4
Disability 5
Day of the accident/event(DD)
Yes – provide
– provide the date of
Day of claim finalised (DD)
___ /
___ / ___ /
___ / ___ / _________
Was your disability caused by an accident or event? YesNo
Have you sought compensation regarding that accident or event? YesNo
Has the compensation claim been YesNo
Have you received legal advice about your compensation claim? YesNo
Fields on page 12
Signature
Your full name
Date (DD/MM/YYYY)
___ /
___ / ___ /
Fields on page 13
First name
Surname
Professional qualification(s)
Provider registration number
Length of time you’ve treated the applicant
Business name
Number and Street
Suburb
State
Postcode
State
_______________________
Fields on page 14
Applicant’s main disability
– provide details below
Disability 3
functional capacity been affected by
a) Description of current treatments
Does the applicant have any other disabilities? YesNo
Is the impairment time limited and/or degenerative in nature? Option 1Option 2Option 3
Is the impairment currently being treated? YesNo
Fields on page 15
b) Duration/frequency of current treatments
c) Expected results of current treatments
a) Description of previous treatments
b) Duration/frequency of previous treatments
c) Results of previous treatments
□ Yes – provide details below
b) Duration/frequency of available treatments
c)Expected results of available treatments
are likely to substantially relieve the YesNo
Fields on page 16
a) Description of recommended interventions
b) Duration/frequency of recommended interventions
c) Expected results of recommended intervention
future support needs YesNo
The provision of early supports will Option 1Option 2Option 3Option 4
Fields on page 17
Date
Result
Care and Needs Scale (CANS) Attached
Gross Motor Functional Classification Scale (GMFCS)
Gross Motor Functional Classification Scale (GMFCS)
Gross Motor Functional Classification Scale (GMFCS)
Hearing Acuity Score Date
Hearing Acuity Score Result
Hearing Acuity Score Attached
Diagnostic & Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) Date
Diagnostic & Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) Result
Diagnostic & Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) Attached
Visual Acuity Score Date
Visual Acuity Score Result
Visual Acuity Score Attached
Communication Function Classification System (CFCS) Date
Communication Function Classification System (CFCS) Result
Communication Function Classification System (CFCS) Attached
Vineland Adaptive Behaviour Scale (Vineland-II) Date
Vineland Adaptive Behaviour Scale (Vineland-II) Result
Vineland Adaptive Behaviour Scale (Vineland-II) Attached
Modified Rankin Scale (mRS) Date
Modified Rankin Scale (mRS) Result
Modified Rankin Scale (mRS) Attached
Manual Ability Classification Scale (MACS)
Manual Ability Classification Scale (MACS) Result
Manual Ability Classification Scale (MACS) Attached
American Spinal Injury Association Impairment Scale (ASIA/AIS) Date
American Spinal Injury Association Impairment Scale (ASIA/AIS) Result
American Spinal Injury Association Impairment Scale (ASIA/AIS) Attached
Disease Steps Date
Disease Steps Result
Disease Steps Attached
Expanded Disability Status Scale (EDSS)
Expanded Disability Status Scale (EDSS) Result
Expanded Disability Status Scale (EDSS) Attached
Health of the Nation Outcome Scales (HoNOS)
Health of the Nation Outcome Scales (HoNOS) Result
Health of the Nation Outcome Scales (HoNOS) Attached
Life Skills Profile 16 (LSP-16) Date
Life Skills Profile 16 (LSP-16) Result
Life Skills Profile 16 (LSP-16) Attached
Other Date
Other Result
Other Attached
Have any of the following assessments been completed with the applicant? YesNo
Fields on page 18
Affected life activities
How does the applicant’s disability substantially impact their functional capacity? Option 1Option 2Option 3Option 4Option 5Option 6
Fields on page 19
through spoken, written and/or non-
interacting with the community, and
remembering information, and using
as hygiene, grooming, feeding and
Affected life activities by Self-Management
Fields on page 20
Specify type and frequency of assistance required Home and/or environment modifications
Specify type and frequency of assistance required Assistive equipment and technology
Specify type and frequency of assistance required Assistance from other persons
Specify type and frequency of assistance required Home and/or environment modifications 1
Specify type and frequency of assistance required Assistive equipment and technology 1
What type(s) of mobility assistance does the applicant need to participate in the life activities listed above? Option 1Option 2Option 3
What type/s of communication assistance does the applicant need to participate in the life activities listed above? Option 1Option 2Option 3
Fields on page 21
Section 2: The Treating Professional
does the applicant need to participate in the life
Specify type and frequency of assistance required Assistive equipment and technology 2
Specify type and frequency of assistance required Assistance from other persons 2
Specify type and frequency of assistance required Home and/or environment modifications 3
What type/s of social interaction assistance does the applicant need to participate in the life activities listed above? Option 1Option 2Option 3
What type/s of learning assistance does the applicant need to participate in the life activities listed above? Option 1Option 2Option 3
Fields on page 22
Section 2: The Treating Professional
Specify type and frequency of assistance required Assistance from other persons 3
Specify type and frequency of assistance required Home and/or environment modifications 4
Specify type and frequency of assistance required Assistive equipment and technology 4
Specify type and frequency of assistance required Assistance from other persons 4
What type/s of self-care assistance does the applicant need to participate in the life activities listed above? Option 1Option 2Option 3
Fields on page 23
does the applicant need to participate in the life
Specify type and frequency of assistance required Assistive equipment and technology 5
Specify type and frequency of assistance required Assistance from other persons 5
What type/s of self-management assistance does the applicant need to participate in the life activities listed above? Option 1Option 2Option 3
Fields on page 24
Do you want to provide any further information
Fields on page 25
Treating Professional’s signature 1
Treating Professional’s full name
Date
Fields on page 26
Part A: Applicant's Information
Part B: Privacy and Consent Declaration
Part C: Contact Methods
Part D: Parent, Legal Guardian, or Representative Information (if applicable)
Part E: Overview of Disability
Part F: Applicant or Representative Signature and Declaration
Attachments: Information/evidence of Authorised or Legal representative (if applicable)
Attachments: Information/evidence of disability and/or functional capacity (if applicable)
Part A: Treating Professional's Information
Part B: Evidence of Disability
Part C: Early Intervention Support Needs
Part D: Existing Assessments
Part E: Evidence of Functional Capacity
Part F: Additional Notes
Part G: Treating Professional’s Signature and Declaration
