NDIS Access Request Form

NDIS Access Request – GP Supporting Evidence Template Patient Details: - Name: John Smith - Date of Birth: 12/03/1980 - Address: 123 Main Street, Anytown, NSW 2000 Treating Professional Details: - Name: Dr. Jane Doe - Qualification(s): MBBS, FRACGP - Provider Number: 1234567A - Practice Address: The Family Practice, 456 Oak Avenue, Anytown, NSW 2000 - Contact Number: 02 9876 5432 - Email: jane.doe@email.com - Duration of Treatment: 5 years Primary Disability: - Diagnosis: Major Depressive Disorder - Date of Diagnosis: 15/06/2018 - Is the condition permanent? Yes - Is the condition likely to be lifelong? Yes Secondary Disabilities (if any): - Diagnosis: Generalised Anxiety Disorder Medical History: - Relevant medical and surgical history: Appendectomy in 2010. - Relevant family history: Father with history of depression. - Relevant social history: Smoker, 10 cigarettes per day. - Allergies and reactions: NKDA - Current medications: Sertraline 100mg daily, Clonazepam 0.5mg as required. Functional Impact: - Mobility: No significant impact. - Communication: No significant impact. - Social Interaction: Difficulty maintaining relationships and social isolation. - Learning: Difficulty concentrating and impaired memory. - Self-Care: No significant impact. - Self-Management: Difficulty managing finances and attending appointments. Treatment History: - Previous Treatments: CBT, unsuccessful. - Current Treatments: Sertraline and Clonazepam, with partial response. - Future Treatment Options: Referral to a psychiatrist for review of medication and consideration of ECT. Additional Information: - The patient requires support with daily living activities due to the impact of their mental health conditions. Declaration: I, Dr. Jane Doe, confirm that the above information is accurate to the best of my knowledge and based on my professional assessment of John Smith. Signature: Date: 01/11/2024