<Letterhead>

To National Disability Insurance Agency
GPO Box 700
Canberra, ACT, 2601
Email: NAT@ndis.gov.au

To whom it may concern,

Re: <PtName>
<PtAddress>
Patient DOB: <PtDoB>
Patient native language:
<PtLanguage Spoken>
Is interpreter reqired? <Is interpreter required?>

Thank you for considering this person for inclusion in the National Disability Insurance Scheme. I am a  <DrName> employed by <Practice> and currently provide them with health care. <PtName>  has been a patient of our service since  .../.../20... I last saw patient <PtSurname> on the .../.../2018. 
Patient goals and aspirations:
Include what the patient is hoping to achieve through the NDIS plan, particularly about their immediate and essential needs. Before including any recommendation on a specific support, make sure that the support will align to the patient's goals. 		

Guardian or carer is aware of the application process 		<Guardian or carer is aware of the application proces>	

<PtName> has been diagnosed with the following:
Primary Disability:
Primary and permanent disability/ mental illness  (Brief Description, if possible)	Please use most adequative condition for this application:
<PMHAll>	
Secondary Disability/illness:
Secondary illnesses (disability/ health) impacting on their functional capacity. Whilst chronic health conditions may impact a person functional capacity, they are not relevant to an NDIS application.	<PMHAll>	
	 
Please refer to attached diagnostic report (remove if no diagnostic report available).	   

Current Treatment/Intervention:
In this section it is recommended to include all the patient’s known ongoing health interventions and current therapies. Please include information re interventions and discharge plan for the patient. 		
Formal Support:
 In this section it is recommended to include all the patient’s known formal disability supports eg Health, Education, Provider. Name and contact numbers for the disability supports can be included here. 	

Psychosocial History:
In this section include current circumstances, living arrangements, other factors relevant to the application (ie: guardianship status, Housing support, support decision making, advocacy, frequent homelessness, excess drug use, sense of ‘hopelessness’).	

	
Informal Support:
In this section include all the patients known informal appropriate supports such as family, friends and community supports.	

Please see below supporting information about <PtName> 's disability and the impact it has on their daily life.

1. Mobility 
Moving around (crawling/walking), getting in or out of bed or a chair, managing physical tasks (e.g. lifting, balancing, sitting), leaving the home and moving about in the community. 	
Does the person require assistance to be mobile because of their disability?	☐No, does not need assistance
☐Yes, needs special equipment
☐Yes, needs assistive technology
☐Yes, needs assistance from other persons:
(physical assistance, guidance, supervision or prompting)	
If yes, please describe the type of practical assistance required and attach any additional evidence related to the applicant’s mobility/motor skills (including access to the community or when fatigued):

	
2. Communication
Being able to express themselves and be understood in spoken, written or alternative modalities (eg. sign language, use of technology) and understanding others through appropriate modalities of communication. 	
Does the person require assistance to communicate effectively because of their disability?	
☐No, does not need assistance
☐Yes, needs special equipment
☐Yes, needs assistive technology
☐Yes, needs assistance from other persons:
(physical assistance, guidance, supervision or prompting)	
If yes, please describe the type of practical assistance required and attach any additional evidence related to the applicant’s communication skills (especially in a busy community location, in a new activity, or with unknown people):

	
3. Social Interaction
Maintaining family relationship (e.g.: family, parent, children), making and keeping friends, interacting with the community (or playing with other children), coping with feelings and emotions.	
Does the person require assistance to Interact socially because of their disability?	
☐No, does not need assistance
☐Yes, needs special equipment
☐Yes, needs assistive technology
☐Yes, needs assistance from other persons:
(physical assistance, guidance, supervision or prompting)	
If yes, please describe the type of practical assistance required (subtle or explicit) and attach any additional evidence related to the applicant’s social interaction skills (including in a busy community location, in a new activity, or with unknown people):

	
4. Learning
Understanding and remembering information, learning new things, practising and using new skills (e.g.: cooking skills, using internet, catching bus to a new place), adjusting to ‘Life’ changes (e.g.: moving house, starting a new job).	
Does the person require assistance to learn effectively because of their disability?	☐No, does not need assistance
☐Yes, needs special equipment
☐Yes, needs assistive technology
☐Yes, needs assistance from other persons:
(physical assistance, guidance, supervision or prompting)	
If yes, please describe the type of practical assistance required (subtle or explicit) and attach any additional evidence related to the applicant’s learning ability (including in a busy community location or in a new location / activity/ cognitive profile):

	
5. Self-Care
Showering/ bathing, dressing, eating toileting, caring for own health (not applicable for children under two years of age). 	
Does the person require assistance with self-care because of their disability?	☐No, do not need assistance
☐Yes, need equipment/ assistive technology
☐Yes, need assistance from another person in the areas of:
☐showering/bathing ☐ toileting
☐eating/drinking ☐ dressing
☐overnight care (e.g. turning)	
If yes, please describe the type of practical assistance required (subtle or explicit) and attach any additional evidence related to the applicant’s ability to self-care (including when fatigued. Note if durations may be significantly longer than normal):

	
6. Self-Management
Doing daily jobs, making decisions and handling problems and money (e.g.: planning daily activities, booking appointments (medical/dental/haircut), maintain employment/education/tenancy, managing finances, paying bills, participating in hobbies). 	
Does the person require assistance with self-management because of their disability?	☐No, does not need assistance
☐Yes, needs special equipment
☐Yes, needs assistive technology
☐Yes, needs assistance from other persons:
(physical assistance, guidance, supervision or prompting	
If yes, please describe the type of practical assistance required (subtle or explicit) and attach any additional evidence related to the applicant’s self-management ability:
Please note the ability to carry out the whole sequence, the quality of the planning, the ability to complete the task as planned, and the ability to adjust the plan in real-time when problems arise. 

	

Due to the nature of this person’s disability or their social circumstances, do they/ their guardian require an advocate during the NDIS planning process if deemed eligible.	☐No, 
☐Yes,	
The person most appropriate to assist during their NDIS application/ planning process is:
Name: Name of the advocate
Relationship: 
☐  Family
☐  Friend
☐  Carer
☐  Other
Contact Details: 
Advocate consents to be contacted by NDIA: YES ☐NO☐                    	

Recommendation:
In my professional opinion <PtName>has a disability that is likely to permanently and substantially reduce their functional capacity in a number of areas including social or/and economic participation. He/ She is likely to permanently require assistance from the NDIS to effectively manage the impacts of the condition.

Based on <PtName> needs and aforementioned patient’s goals and aspirations, it is my recommendation that the following services, supports, modification and/or equipment are required to support her/him to maintain functional capacity and manage with the impacts of the permanent disability:
In this section comment on what disability supports and equipment the patient may benefit from and explain why. (Concentrating on the disability supports that will be beneficial for the patient to maintain function on the domain areas: communication, social interaction, mobility, learning, self-care and self-management) 

	

Please do not hesitate to contact me regarding any of the above information.

Yours Sincerely,

* NOTE: please ensure you have removed all  red instructions provided in this template. 
Signature of person completing report:	
SIGN

Name of person/s completing report:	
<DrDetails>
				Date:		<Date>
				 
Organisation:							 
<Practice>