Confirmation Questionnaire

Client Name *

First

Last

NDIS Number, if applicable

Address of the property being assessed: *

Best Contact Name on the day of the appointment (i.e, n.o.k, support coordinator, carer) *

First

Last

Phone Number *

If you experience any symptoms of Influenza, COVID19 or other highly contagious illnesses, in the days leading up to the appointment, please advise us and we will make alternative arrangements to accommodate. *

If the client is immunocompromised, please let us know in the comments section below and our OT can wear a mask for the client's safety.

Best Place for parking and acessing the property (including steps, gates access codes, dor bells, lifts)

Any Animals or other safety requirements for visiting the property? (i.e Tip hazzards)

Have you submitted to YCOT any Allied Health reports that are imperative to providing evidence of the clients diagnosed condition and functional ability required for the OT to provide the best recommendations inline with NDIS/MAC requirements. *

Have you submitted to YCOT a copy of your most recent NDIS plan approval wording for home modifications services OR approval for minor modifications/ assistive equipment (only wording on the specifics approved and outlined in the plan is required), and plan dates; no finance information is required. This is so we can determine the NDIS's expectation on which report service they have approved for us to proceed. *

Comments