Dubbo Regional Occupational Therapy (DROT)

NDIS Referral Form

Client must be over the age of 18 and have a physical disability.

Our team does complete Functional Capacity Assessment's, and our skills lie in home modifications and equipment prescription.

Thank you! Your submission has been sent successfully.

I confirm that the client being referred is OVER THE AGE OF 18 and has a PHYSICAL disability

Client First and Last Name

Client Date of Birth

Client Address

Client Contact Number and Email

Referred By (Name and Organisation)

Referrer Contact Number and Email

Participant NDIS Number

NDIS Plan Dates

NDIS funding released in funding blocks?

Funding block dates and amount released for OT

Funding Managed by:

Plan Manager Name

Plan Manager Contact Number and Email

Support Coordinator Name

Support Coordinator Contact Number and Email

Medical Diagnosis

Presenting Problems

OT Intervention Requested

Intervention Additional Information (e.g. Home modifications required are rails, ramps, bathroom, kitchen | Driving Assessment, please indicate Licence Number, Auto/Manual, Date Required By, Has a Medical been completed)