NDIS Assistive Technology Application Form

NDIS Assistive Technology Application Form Participant Details: - Name: John Doe - NDIS Number: 123456789 - Date of Birth: 01/01/1980 - Address: 123 Main Street, Springfield - Contact Number: 0400 123 456 - Email: johndoe@example.com Support Coordinator/Plan Manager Details (if applicable): - Name: Jane Smith - Organisation: Care Support Services - Contact Number: 0400 654 321 - Email: janesmith@caresupport.com Assistive Technology Details: - Type of Assistive Technology: Electric Wheelchair - Purpose of Assistive Technology: To enhance mobility and independence - How will this Assistive Technology help the participant achieve their goals?: The electric wheelchair will enable John to move independently within his home and community, improving his quality of life and allowing him to participate in social activities. Supplier Details: - Supplier Name: Mobility Aids Co. - Contact Person: Mark Johnson - Contact Number: 0400 789 012 - Email: mark.johnson@mobilityaids.com - Address: 456 Elm Street, Springfield Quote Details: - Item Description: Electric Wheelchair Model X - Cost: $5,000 - Delivery Timeframe: 2 weeks Health Professional Details: - Name: Dr. Emily Brown - Profession: Occupational Therapist - Registration Number: OT123456 - Contact Number: 0400 987 654 - Email: emily.brown@healthclinic.com - Address: 789 Oak Avenue, Springfield Health Professional's Recommendation: - Description of Participant's Disability: John has a spinal cord injury resulting in limited mobility. - How the Assistive Technology will support the participant's needs: The electric wheelchair will provide John with the necessary support to navigate his environment safely and independently. - Any additional comments or recommendations: It is recommended that John receives training on the use of the electric wheelchair to maximize its benefits. Participant's Declaration: - I declare that the information provided in this application is true and correct to the best of my knowledge. - Signature: John Doe - Date: 10/10/2023 Health Professional's Declaration: - I declare that the information provided in this application is true and correct to the best of my knowledge. - Signature: Dr. Emily Brown - Date: 10/10/2023