Assessment Enquiry

Assessment Enquiry Form

Who is being Assessed?

Name

First Name

Last Name

Date of Birth

YYYY

Phone

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Referred By

If you have been referred please let us know who referred you.

Has the person been assessed by anyone previously? If so please provide a date for this assessment?

A copy of the report would also be helpful.

Purpose of the Assessment:

Eg – School Funding, NDIS application, Continued NDIS funding, Pension Application or Other

Current Diagnosis:

Significant physical or mental health issues:

GP:

Paediatrician:

Occupation Therapist:

Speech Therapist:

Psychologist:

Other specialist:

PARENT/CARER/SUPPORT PERSON INFORMATION

Name:

Relationship to person:

Mobile Number:

Other Relevant Details:

ADDITIONAL INFORMATION:

Are there any other details that might help us understand your needs:

What timeframe are you hoping to have the assessment undertaken within?

Has anyone explained the costs for the assessment to you?

Yes

How did you hear about our services?

CLIENT NDIS DETAILS:

NDIS Participant No:

NDIS Plan Start and End Dates:

NDIS Funding Category to be used for these services:

Are you Plan Managed?

If yes please provide details for your Plan Manager including: Name, Phone and Email

Are you Self Managed?

If yes please confirm who we should send your invoices to?

Are you NDIS Managed?

If so we will invoice NDIS directly.

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If you need any other assistance in the interim please contact Steph Baker our Practice Manager on 49320432 or via email to admin@lifewise.com.au. Many thanks for your assistance.

Contact us.

admin@lifewise.com.au

(02) 4932 0432 - Maitland

(02) 4948 1226 - Warners Bay

General enquiry

NDIS enquiry