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Evidence of Disability Template   

This Evidence of Disability Template has been developed as a guide to assist GPs in communicating with the National Disability Insurance Agency (NDIA).  

This template can be used by GPs to support applications to the National Disability Insurance Scheme (NDIS) for anyone over the age of 9 years old.  

The content in the template can be modified as appropriate, according to clinical judgement and the patient’s needs. It is to be completed by a practitioner who has experience supporting the patient, and understanding of the impact of their functional impairment. 

It is not a requirement to use this template. GPs may choose to submit their own report, provided it includes sufficient detail about the person’s functional impairments and the impact on their daily activities. 

The terminology included in this template aligns with NDIS eligibility requirements. Focus is placed on documenting the following to support consideration of NDIS eligibility: 

•	The permanence of disability and impairment. This is demonstrated by outlining all treatments undertaken, and confirmation that no further available treatment is likely to remedy or substantially improve impairment. 

•	The likelihood that the person will require disability-related supports for their lifetime, despite any fluctuations in their condition or level of impairment. 

•	The substantial impact on functional capacity in one of more of the six NDIS domains: self-care, learning, mobility, self-management, communication, and social participation. 

•	The impact on the person’s capacity for social and/or economic participation. 

This template is adapted from the SESLHD NDIS Evidence of Disability Template. 

To apply to the National Disability Insurance Scheme (NDIS), applicants must attend an Access Request Meeting with a Local Area Coordinator (LAC).

* NOTE: please ensure you have removed all red text in this template 
 <<Miscellaneous:Practice Letterhead>>

<<Miscellaneous:Date (short)>>

To whom it may concern,

Re: <<Patient Demographics:Full Name>>
<<Patient Demographics:Full Address>>
Patient DOB: <<Patient Demographics:DOB>>
Is interpreter reqired? <<Is interpreter required?>>

Thank you for considering this person for inclusion in the National Disability Insurance Scheme (NDIS). I am a General Practitioner from <<Practice:Name>>. I currently provide <<Patient Demographics:Full Name>> with medical care. <<Patient Demographics:Full Name>>  has been a patient of our service since  <<patient of the practice since mm/yyyy>> and has been regularly assessed for the duration of this period.   
This communication is to support <<Patient Demographics:Full Name>>'s NDIS eligibility application and to meet the need for supporting medical evidence. 
Patient Details

Name:
Preferred Name:
Known by or used any other name:

<<Patient Demographics:Full Name>>
<<Patient Demographics:Known As>>
<<Known by or used any other name>>

Date of birth: | <<Patient Demographics:DOB>>

Gender:

<<Gender Identity>>
<<Patient Demographics:Sex at Birth>>

Pronouns: | <<Pronoun>>
Country of birth: | <<Patient Demographics:Country of Birth>>
Home address: | <<Patient Demographics:Address>>
Postal address: | <<Patient Demographics:Full Address Postal>>
Phone number: | Ph:<<Patient Demographics:Phone (Home)>>Work: <<Patient Demographics:Phone (Work)>>Mob:<<Patient Demographics:Phone (Mobile)>>
Email: | <<Patient Demographics:E-mail>>
Preferred contact method: | <<Preferred contact method>>
Opt in to surveys: | <<Opt in to surveys?>>
Do they want to be notified via email/sms of changes made to their account? | <<Notified via email/sms of changes>>

Identify as Aboriginal and/or Torres
Strait Islander or South Sea Islander?

<<Patient Demographics:ATSI>>

Identify as CALD – Culturally and Linguistically Diverse? | <<Identify as CALD?>>

Preferred Language Used at home

<<Patient Demographics:Language Spoken>>
<<Patient Demographics:Language Preferred>>

<<Patient Demographics:First Name>> <<Check NDIS Access, call 1800800110>>
<<Patient Demographics:First Name>> was diagnosed with <<PMHAII - diagnosis>> on <<Date of diagnosis>> <<Briefly explain in plain English what the diagnosis >>
Briefly explain in plain English what the diagnosis means. 

The following are <<Patient Demographics:First Name>>'s significant and permanent impairments associated with their diagnosis or diagnoses: 

Briefly describe the impairments related to the person’s disability and impact on function.  

E.g. Mr Brown experienced a stroke, resulting in permanent cognitive and physical impairments that significantly limit his daily functioning.  

Cognitive impairment has resulted in difficulties planning and carrying out tasks, impacting his ability to complete activities such as scheduling appointments and shopping. Difficulties understanding spoken information impact his ability to participate in social activities.   

Physical impairment has resulted in loss of functional use in his right arm and leg, affecting his ability to stand, walk, and perform self-care tasks like dressing and bathing. 

<<PMHAII>>

The following investigations, treatments and interventions have been completed:
Investigation/Treatment/ Intervention | Outcome

List all investigations and treatments the patient has undergone to satisfy the requirement that health interventions are no longer able to improve each impairment and associated functional loss.  
E.g. Scans, surgical interventions, medication changes/optimisation, previous medications trialled, rehabilitation or AH input (# of sessions), other assessments.
<List all investigations/treatments/interventions>

<Outcome of investigations>

The following interventions and treatments have been considered however are not recommended:
Treatment/ Intervention | Reason treatment not recommended

E.g. surgical interventions, medication changes/optimisation, rehabilitation or AH input.
<Interventions/treatments NOT recommended>

<Why Interventions/treatments NOT recommended?>

 <<Patient Demographics:First Name>> is considered to be fully treated and stabilized. They are not expected to make further substantial gains. <<Patient Demographics:First Name>> has now plateaued, and they will require lifelong supports as a result of the substantial functional impact their disability has on their ability to participate in everyday life.   

<<Patient Demographics:First Name>>’s disability and associated impairments result in a condition that is permanent / likely to be permanent and impacts significantly on their daily life.

Please see below supporting information about <<Patient Demographics:First Name>>'s disability and the impact it has on their daily life.  

1. Mobility
Moving around at home and in the community (e.g. walking or using mobility aids); changing and maintaining body positions (e.g. getting in and out of bed or a chair); managing physical tasks (e.g. carrying, lifting, balancing, sitting and standing); travelling to and navigating locations 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)
[]Unknown, referral to relevant professional provided

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): 
E.g. Mr Brown has significant and permanent physical limitations in his lower limbs following a stroke, which severely restrict his ability to mobilise independently. He requires a quad stick to walk indoors and for short outdoor distances. He cannot safely navigate stairs without hands-on assistance from another person. For longer distances, he requires a wheelchair to access the community. He needs support from others when crossing roads, navigating crowded environments, or walking on uneven surfaces to prevent falls and ensure safety. Without these mobility aids and assistance, Mr Brown is unable to move safely within his home or participate in community activities. His mobility limitations reduce his independence, as he requires ongoing support and equipment to maintain safety and access. <PMHAll>

2. Communication
Expressing themselves and being understood by others through spoken, written or alternative modalities (e.g. sign language or communication device); understanding the communications of others.

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)
[]Unknown, referral to relevant professional provided

If yes, please describe the type of practical assistance required and attach any additional evidence related to the applicant’s communication skills, (especially in busy locations, during new activities, or with unfamiliar people): 
E.g. Following a stroke, Mr Brown has significant and permanent limitations in his ability to understand what is said to him. He experiences difficulties following verbal directions. For example, when shopping, he is unable to understand directions given by shop staff to locate products. He requires physical guidance to support his understanding of verbal directions. His communication limitations reduce his independence, as he requires ongoing support to understand what is said to him. <PMHAll>

3. Social Interaction
Maintaining relationships with family members and other significant people; making and maintaining friendships; interacting with others in the community; participating in recreational activities; and managing feelings, emotions and social situations.

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)
[]Unknown, referral to relevant professional provided

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 busy locations, during new activities, or with unfamiliar people): 
E.g. Mr Brown has significant and permanent limitations in social interaction due to communication difficulties following a stroke. He has difficulties engaging in conversation in group settings. For example, during meals with familiar family and friends, he requires others to repeat and simplify information, and assist him to communicate his thoughts coherently by asking clarifying questions. Without this ongoing support, he is unable to participate in group discussion, which limits his ability to maintain social relationships. <PMHAll>

4. Learning
Understanding, remembering and applying information; learning and using new skills (e.g. cooking, using the internet, catching a bus to unfamiliar locations); solving problems; making decisions; and adapting to life changes (e.g. moving house or 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)
[]Unknown, referral to relevant professional provided

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 busy or new locations / activities): 

E.g. Mr Brown has significant and permanent limitations in learning and applying information following a stroke. For example, he requires prompting to remember to refer to and consistently follow his medication schedule. He cannot reliably manage his medications independently and requires ongoing support. <PMHAll>

5. Self-Care
Showering / bathing; toileting; dressing; eating and drinking; caring for own health.

Does the person require assistance with self-care because of their disability?

[]No, does not need assistance
[]Yes, needs special equipment/needs assistive technology
[]Yes, needs assistance from other persons:
(physical assistance, guidance, supervision or prompting) of:
☐showering/bathing ☐ toileting
☐eating/drinking ☐ dressing
☐overnight care (e.g. turning)
[]Unknown, referral to relevant professional provided

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): 

E.g. As a result of this stroke, Mr Brown has impaired sensation and motor coordination in his right arm and right hand, and he has a right-sided inattention. He requires another person to physically position items and equipment for use and provide stand-by assistance for showering and dressing tasks. Without this ongoing support, he is unable to safely and effectively complete personal care activities. <PMHAll>

6. Self-Management
Planning and completing daily tasks; making decisions and solving problems (e.g. by adjusting plans in real-time when problems arise); managing time and responsibilities; arranging and attending appointments (e.g. medical, dental, haircut); maintaining employment, education or housing; managing finances; participating in hobbies and community activities.

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)
[]Unknown, referral to relevant professional provided

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. 

E.g. Mr Brown has significant and permanent limitations in self-management following a stroke. For example, he requires someone to coordinate appointments on his behalf. He is unable to independently book appointments using the phone or online forms, record appointment details, or prepare attendance by planning how to arrive on time. Without this ongoing support, he is unable to manage his appointment schedule. 

 <PMHAll>

 <<Patient Demographics:Full Name>> will require support from the NDIS to effectively manage the impacts of the condition for their lifetime.  

Any other relevant information 

Any other relevant information

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

Yours Sincerely,

Signature of person completing report:	
SIGN

Name of person/s completing report:	
<<Doctor:Full Details>>
Date:	<<Miscellaneous:Date>>
				 
Organisation:							 
<<Practice:Name>>

* NOTE: please ensure you have removed all red text in this template.