NDIS Access Request Form

NDIS Access Request Form **Participant Details** * **Given Name(s):** Sarah * **Family Name:** Johnson * **Date of Birth:** 15 January 1998 * **Gender:** Female * **Address:** 123 Maple Street, Suburbville, NSW 2000 * **Contact Number:** 0412 345 678 * **Email:** sarah.johnson@example.com **Primary Disability/Condition:** * Cerebral Palsy, Spastic Diplegia type **Impact of Disability/Condition:** * Significant functional limitations affecting mobility, fine motor skills, and daily living activities. * Requires assistance with personal care, household tasks, and community participation. * Experiences chronic pain and fatigue, impacting capacity for employment and social engagement. **Current Supports:** * Family support for daily living. * Weekly physiotherapy sessions (private). * Occasional occupational therapy (private). * Wheelchair and other mobility aids (self-funded). **Reasons for NDIS Access Request:** * To obtain funding for ongoing therapy services (physiotherapy, occupational therapy, speech therapy). * To access assistive technology to improve independence and mobility (e.g., power wheelchair, home modifications). * To receive support coordination to navigate the NDIS and connect with appropriate service providers. * To fund personal care support to enable participation in social and community activities. * To support employment goals through vocational training and workplace modifications. **Medical Professional Details:** * **Name:** Dr. Emily White * **Specialty:** General Practitioner * **Contact Number:** 02 9876 5432 * **Email:** dr.white@medclinic.com.au * **Clinic/Practice Name:** Suburbville Medical Centre * **Address:** 456 Oak Avenue, Suburbville, NSW 2000 **Date of Assessment:** 1 November 2024 **Signature of Medical Professional:** (Electronic Signature of Dr. Emily White) **Relevant Medical History/Supporting Documentation (attached):** * Neurological assessment report from 2022. * Physiotherapy assessment report from October 2024. * Occupational therapy assessment report from September 2024. * Summary of medical history from GP records. **Declaration:** I confirm that the information provided in this form is accurate to the best of my knowledge and that I have discussed this NDIS Access Request with the participant, Sarah Johnson. **Date of Completion:** 1 November 2024