MH NDIS REPORT (Australia Only)

Psychiatry & Psychology
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NDIS Access Request Report

Date: [text name="variable_1" default=""]

To Whom It May Concern,

Re: Letter in support of NDIS Access Request for [text default="NAME"]

I am assisting [text default="NAME"] with requesting access to the National Disability Insurance Scheme (NDIS). This individual has been a patient of
[text default="Area"] Community Mental Health since [text default="DATE"] for mental health treatment, and clinical care coordination.

My details are:

Clinician: [text default=""]
Professional qualification: [text default=""].
Address: [text default=""]
Phone Number: [text default=""]
Fax: [text default=""]

1.0 DIAGNOSES

Diagnosis: [text default=""]
Date of Diagnosis: [text default=""]
Diagnosis Made By: [text default=""]
Is it likely to be permanent? [text default=""]

Please see supporting evidence relating to the diagnosis attached.

1.2 APPLICABLE DIAGNOSITC CATEGORIES:

[checkbox value="Intellectual Disability|Physical Disability|Cognitive Disability|Psychiatric/Psychosocial Disability|Neurological Disability|Developmental Delay|Sensory Disability|N/A"]

1.3 APPLICABLE PROVISION OF EARLY INTERVENTION SUPPORTS:

[checkbox value="Alleviate the impact of the person’s impairment|Prevent deterioration of the person’s impairment|Improve functional capacity|Strengthen the sustainability of available or existing supports"]

If applicable, details of recommended early intervention supports:

[textarea name="variable_1" default="N/A"]

1.4 BRIEF DESCRIPTION OF TREATMENT:

-- Past Treatments and Outcomes --

(previous medications, aids, protective equipment, and assistive technology)

[checkbox name="aggress" value="Condition: overactive, aggressive, disruptive or agitated behaviour."][conditional field="aggress" condition="(aggress).is('Condition: overactive, aggressive, disruptive or agitated behaviour.')"] Treatment: [checkbox value="medication|legal bond|psychological counselling|behavioural|psychosocial|medical"] [textarea cols=80 rows=5 default="Outcome: no longer a problem,still a minor problem requiring no action, remains a mild problem,remains a moderately severe problem,remains a severe to very severe problem"][/conditional]

[checkbox name="inj" value="Condition: Non-accidental self-injury."][conditional field="inj" condition="(inj).is('Condition: Non-accidental self-injury.')"] Treatment: [checkbox value="medication|legal bond|psychological counselling|behavioural|psychosocial|medical"] [textarea cols=80 rows=5 default="Outcome: no longer a problem,still a minor problem requiring no action, remains a mild problem,remains a moderately severe problem,remains a severe to very severe problem"][/conditional]

[checkbox name="drug" value="Condition: Problem-drinking or drug-taking."][conditional field="drug" condition="(drug).is('Condition: Problem-drinking or drug-taking.')"] Treatment: [checkbox value="medication|legal bond|psychological counselling|behavioural|psychosocial|medical"] [textarea cols=80 rows=5 default="Outcome: no longer a problem,still a minor problem requiring no action, remains a mild problem,remains a moderately severe problem,remains a severe to very severe problem"][/conditional]

[checkbox name="cog" value="Condition: Cognitive problems."][conditional field="cog" condition="(cog).is('Condition: Cognitive problems.')"] Treatment: [checkbox value="medication|legal bond|psychological counselling|behavioural|psychosocial|medical"] [textarea cols=80 rows=5 default="Outcome: no longer a problem,still a minor problem requiring no action, remains a mild problem,remains a moderately severe problem,remains a severe to very severe problem"][/conditional]

[checkbox name="phys" value="Condition: Physical illness or disability problems."][conditional field="phys" condition="(phys).is('Condition: Physical illness or disability problems.')"] Treatment: [checkbox value="medication|legal bond|psychological counselling|behavioural|psychosocial|medical"] [textarea cols=80 rows=5 default="Outcome: no longer a problem,still a minor problem requiring no action, remains a mild problem,remains a moderately severe problem,remains a severe to very severe problem"][/conditional]

[checkbox name="delu" value="Condition: Problems associated with hallucinations and delusions."][conditional field="delu" condition="(delu).is('Condition: Problems associated with hallucinations and delusions.')"] Treatment: [checkbox value="medication|legal bond|psychological counselling|behavioural|psychosocial|medical"] [textarea cols=80 rows=5 default="Outcome: no longer a problem,still a minor problem requiring no action, remains a mild problem,remains a moderately severe problem,remains a severe to very severe problem"][/conditional]

[checkbox name="dep" value="Condition: Problems with depressed mood."][conditional field="dep" condition="(dep).is('Condition: Problems with depressed mood.')"] Treatment: [checkbox value="medication|legal bond|psychological counselling|behavioural|psychosocial|medical"] [textarea cols=80 rows=5 default="Outcome: no longer a problem,still a minor problem requiring no action, remains a mild problem,remains a moderately severe problem,remains a severe to very severe problem"][/conditional]

[checkbox name="other" value="Condition: Other mental and behavioural problems."][conditional field="other" condition="(other).is('Condition: Other mental and behavioural problems.')"] Treatment: [checkbox value="medication|legal bond|psychological counselling|behavioural|psychosocial|medical"] [textarea cols=80 rows=5 default="Outcome: no longer a problem,still a minor problem requiring no action, remains a mild problem,remains a moderately severe problem,remains a severe to very severe problem"][/conditional]

[checkbox name="adl" value="Condition: Problems with activities of daily living."][conditional field="adl" condition="(adl).is('Condition: Problems with activities of daily living.')"] Treatment: [checkbox value="medication|legal bond|psychological counselling|behavioural|psychosocial|medical"] [textarea cols=80 rows=5 default="Outcome: no longer a problem,still a minor problem requiring no action, remains a mild problem,remains a moderately severe problem,remains a severe to very severe problem"][/conditional]

[checkbox name="liv" value="Condition: Problems with living conditions."][conditional field="liv" condition="(liv).is('Condition: Problems with living conditions.')"] Treatment: [checkbox value="medication|legal bond|psychological counselling|behavioural|psychosocial|medical"] [textarea cols=80 rows=5 default="Outcome: no longer a problem,still a minor problem requiring no action, remains a mild problem,remains a moderately severe problem,remains a severe to very severe problem"][/conditional]

[checkbox name="occ" value="Condition: Problems with occupation and activities."][conditional field="occ" condition="(occ).is('Condition: Problems with occupation and activities.')"] Treatment: [checkbox value="medication|legal bond|psychological counselling|behavioural|psychosocial|medical"] [textarea cols=80 rows=5 default="Outcome: no longer a problem,still a minor problem requiring no action, remains a mild problem,remains a moderately severe problem,remains a severe to very severe problem"][/conditional]

-- Current Treatments --

(list current medication, aids and protective equipment and if these are expected to improve the symptoms or if they are for maintenance only)

[checkbox name="aggress" value="Condition: overactive, aggressive, disruptive or agitated behaviour."][conditional field="aggress" condition="(aggress).is('Condition: overactive, aggressive, disruptive or agitated behaviour.')"] Treatment: [checkbox value="medication|legal bond|psychological counselling|behavioural|psychosocial|medical"] [textarea cols=80 rows=5 default="Outcome: no longer a problem,still a minor problem requiring no action, remains a mild problem,remains a moderately severe problem,remains a severe to very severe problem"][/conditional]

[checkbox name="inj" value="Condition: Non-accidental self-injury."][conditional field="inj" condition="(inj).is('Condition: Non-accidental self-injury.')"] Treatment: [checkbox value="medication|legal bond|psychological counselling|behavioural|psychosocial|medical"] [textarea cols=80 rows=5 default="Outcome: no longer a problem,still a minor problem requiring no action, remains a mild problem,remains a moderately severe problem,remains a severe to very severe problem"][/conditional]

[checkbox name="drug" value="Condition: Problem-drinking or drug-taking."][conditional field="drug" condition="(drug).is('Condition: Problem-drinking or drug-taking.')"] Treatment: [checkbox value="medication|legal bond|psychological counselling|behavioural|psychosocial|medical"] [textarea cols=80 rows=5 default="Outcome: no longer a problem,still a minor problem requiring no action, remains a mild problem,remains a moderately severe problem,remains a severe to very severe problem"][/conditional]

[checkbox name="cog" value="Condition: Cognitive problems."][conditional field="cog" condition="(cog).is('Condition: Cognitive problems.')"] Treatment: [checkbox value="medication|legal bond|psychological counselling|behavioural|psychosocial|medical"] [textarea cols=80 rows=5 default="Outcome: no longer a problem,still a minor problem requiring no action, remains a mild problem,remains a moderately severe problem,remains a severe to very severe problem"][/conditional]

[checkbox name="phys" value="Condition: Physical illness or disability problems."][conditional field="phys" condition="(phys).is('Condition: Physical illness or disability problems.')"] Treatment: [checkbox value="medication|legal bond|psychological counselling|behavioural|psychosocial|medical"] [textarea cols=80 rows=5 default="Outcome: no longer a problem,still a minor problem requiring no action, remains a mild problem,remains a moderately severe problem,remains a severe to very severe problem"][/conditional]

[checkbox name="delu" value="Condition: Problems associated with hallucinations and delusions."][conditional field="delu" condition="(delu).is('Condition: Problems associated with hallucinations and delusions.')"] Treatment: [checkbox value="medication|legal bond|psychological counselling|behavioural|psychosocial|medical"] [textarea cols=80 rows=5 default="Outcome: no longer a problem,still a minor problem requiring no action, remains a mild problem,remains a moderately severe problem,remains a severe to very severe problem"][/conditional]

[checkbox name="dep" value="Condition: Problems with depressed mood."][conditional field="dep" condition="(dep).is('Condition: Problems with depressed mood.')"] Treatment: [checkbox value="medication|legal bond|psychological counselling|behavioural|psychosocial|medical"] [textarea cols=80 rows=5 default="Outcome: no longer a problem,still a minor problem requiring no action, remains a mild problem,remains a moderately severe problem,remains a severe to very severe problem"][/conditional]

[checkbox name="other" value="Condition: Other mental and behavioural problems."][conditional field="other" condition="(other).is('Condition: Other mental and behavioural problems.')"] Treatment: [checkbox value="medication|legal bond|psychological counselling|behavioural|psychosocial|medical"] [textarea cols=80 rows=5 default="Outcome: no longer a problem,still a minor problem requiring no action, remains a mild problem,remains a moderately severe problem,remains a severe to very severe problem"][/conditional]

[checkbox name="adl" value="Condition: Problems with activities of daily living."][conditional field="adl" condition="(adl).is('Condition: Problems with activities of daily living.')"] Treatment: [checkbox value="medication|legal bond|psychological counselling|behavioural|psychosocial|medical"] [textarea cols=80 rows=5 default="Outcome: no longer a problem,still a minor problem requiring no action, remains a mild problem,remains a moderately severe problem,remains a severe to very severe problem"][/conditional]

[checkbox name="liv" value="Condition: Problems with living conditions."][conditional field="liv" condition="(liv).is('Condition: Problems with living conditions.')"] Treatment: [checkbox value="medication|legal bond|psychological counselling|behavioural|psychosocial|medical"] [textarea cols=80 rows=5 default="Outcome: no longer a problem,still a minor problem requiring no action, remains a mild problem,remains a moderately severe problem,remains a severe to very severe problem"][/conditional]

[checkbox name="occ" value="Condition: Problems with occupation and activities."][conditional field="occ" condition="(occ).is('Condition: Problems with occupation and activities.')"] Treatment: [checkbox value="medication|legal bond|psychological counselling|behavioural|psychosocial|medical"] [textarea cols=80 rows=5 default="Outcome: no longer a problem,still a minor problem requiring no action, remains a mild problem,remains a moderately severe problem,remains a severe to very severe problem"][/conditional]

-- Other Treatment Options --

Please list other treatment options not trialed and or considered. State the reason (e.g. medication interaction, impact of other impairments, affordability)

Other Treatment Options: [textarea name="variable_1" default="sample text"]

Reasons: [textarea name="variable_1" default="sample text"]

1.5 LEVEL OF IMPAIRMENT ASSESSMENTS

Assessment Type: [checkbox value="WHODAS|LSP-16|ABAS|Nil|N/A"]
Date Completed: [text name="variable_1" default="sample text"]
Score or Rating Conclusion: [text name="variable_1" default="sample text"]

Please see assessment attached to this report.

2.0 FUNCTIONAL CAPACITY

Person’s name has substantial reduced functional capacity in the following domains because of their impairment/s:

2.1 COMMUNICATION

Does the person require assistance to communicate because of their impairment/s?

[checkbox value="No, does not need assistance in this area|.Yes, needs assistance to communicate their needs or wants|Yes, needs assistance to understand others, follow instructions and directions.|Yes, needs assistance to initiate and maintain conversations|Yes, needs assistance to communicate with professionals about health and social supports|Yes, needs special equipment, assistive technology and/or assistance from other people"].

-- Description of area of need --

[checkbox value="N/A|• Communicating needs & wants|• Following instructions & conversation|• Understanding others|• Understanding directions"]

-- Factors of the illness that create difficulty --

[checkbox value="N/A|• Delusional thinking • Hallucinations • Cognitive difficulties • Depression • Anxiety"]

-- Functional Implications --

[checkbox value="N/A|• Difficulty interpreting communication • difficulty understanding directions"]

-- Physical Health Implications --

[checkbox value="N/A|•Inability to adequately communicate with medical staff|• Inability to understand / recall medication instructions, self-care|• Inability to
adequately explain symptoms experienced"]

-- Type of Support Needed --

[checkbox value="N/A|Patient requires a worker to assist with interactions, especially with appointments, work activities, groups"]

-- Frequency of Support Needed --

[comment memo="Monthly support to attend appointments, weeky support to attend & participate in volunteer group"]

[textarea cols=80 rows=20 default=""]

-- Example Observations --

[comment memo="X has become isolated in the community since being diagnosed with schizophrenia. X experiences symptoms of paranoia & therefore finds it difficult to interact with others, engage in volunteer or paid work & venture independently into the community. X struggles to follow directions & is easily distracted. X is fiercely independent & has limited insight into his ability to complete daily activities & as a result often fails to communicate his own needs for support."]

[textarea cols=80 rows=20 default=""]

2.2 SOCIAL INTERACTION

Does the person require assistance to interact with others because of their impairment/s?

[checkbox value="No, does not need assistance in this area.|Needs assistance to control and cope with emotions.|Needs assistance to maintain family relationships and friendships, is socially isolated and withdrawn.|Needs assistance to interact with strangers in an appropriate manner.|Needs assistance to engage in social and or recreational activities.|Needs assistance with initiating and responding to conversation.|Needs assistance with employment, training or volunteer work.|Needs assistance with driving and or using public transport.|Needs special equipment, assistive technology and/or assistance from other people."]

-- Description of area of need --

[checkbox value="N/A|• Making & keeping friends & relationships|• Behaving within limits accepted by others|• Coping with feelings & emotions|• Having a sense of purpose in life|• Making connections in the community|• Volunteering"]

-- Factors of illness that create difficulty --

[checkbox value="N/A|• PTSD|• Anxiety|• Paranoia|• Hallucination|• Derealisation|• Aggression|• Obsessions|• Poverty of thought|• Depression|• Elevated mood|• Stability of mood|• Social cognitions"]

-- Functional Implications --

[checkbox value="N/A|• Social isolation & withdrawal|• Difficulty with: - Responding to social situations - Making & keeping friends - Talking to strangers or certain people - Interaction affected by behaviours|• Fear or distrust of others"]

-- Physical Health Implications --

[checkbox value="N/A|• Potential lack of acceptance in waiting room|• Potential disturbance to other patients|• Uncomfortable waiting for appointments"]

-- Type of support needed --

[checkbox value="N/A|Person to accompany when attending social activities"]

-- Frequency of support needed --

Attendance at social activities ([checkbox value="0|1|2|3|4|5|6"] hrs/wk) and graded support for new social situations.

-- Example Observations --

[comment memo="X has become socially isolated since being diagnosed with depression. X doesn’t venture into the community alone. X feels very anxious when meeting new people which further adds to his social isolation. X speaks very quickly due to mania, & is frequently unable to speak due to feeling depressed. It is very difficult for X to interact socially & maintain friendships. X has feelings & emotions she is unable to cope with due to her mental illness."]

[textarea cols=80 rows=20 default=""]

-- Assistance required --

[checkbox value="No assistance required in this area|Needs assistance to control and cope with emotions|Needs assistance to maintain family relationships and friendships, is socially isolated and withdrawn|Needs assistance to interact with strangers in an appropriate manner|Needs assistance to engage in social and or recreational activities|Needs assistance with initiating and responding to conversation|Needs assistance with employment, training or volunteer work|Needs assistance with driving and or using public transport|Needs special equipment, assistive technology and/or assistance from other people"].

[comment memo="If yes, please briefly explain the difficulties with social interaction:"]

[textarea cols=80 rows=20 default=""]

2.3 LEARNING

Does the person require assistance to learn new skills because of their impairment/s?

[checkbox value="No, does not need assistance in this area.|Has difficulty in paying attention and focussing on tasks and activities.|Needs assistance to learn, practice and retain new things and skills.|Needs assistance to understand and remember information.|Needs assistance to participate in group learning, classes, tutorials etc.|Needs special equipment, assistive technology and/or assistance from other people."]

-- Description of Need --

[checkbox value="N/A|• Understanding|• Remembering|• Learning new information|• Concentrating"]

-- Factors of Illness that Creat Difficulty --

[checkbox value="N/A|• Cognitive difficulties|• Alertness|| Memory • Orientation • Concentration • Learning • Planning • Compulsions • Hallucinations • Derealisation"]

-- Functional Implications --

Difficulty with: [checkbox value="• Nothing of note|• Organising tasks|• Learning new info|• Following instructions|• Understanding directions|• Making decisions|• Solving problems"]

-- Physical Health Implications --

[checkbox value="N/A|• Remembering medication, administration|• Completing forms eg. screening tests|• Making good health choices, self-care"]

-- Type of Support Needed --

Equipment that assists with recording & organising (e.g. tablet device) Person to assist with learning & engaging in activities

[comment memo="•Needs assistance and equipment that assists with recording & organising (e.g. tablet device)|• Needs a support worker to assist with learning & engaging in activities"]

[textarea cols=80 rows=20 default="Other notes on learning"]

-- Frequency of Support Needed --

[comment memo="Support & training for device use (10hrs over 5 weeks) Assistance with study/rec activities (1hr/wk) Total 6hrs/mth + equipment cost"]

[textarea cols=80 rows=20 default=""]

-- Example Observations --

[comment memo="X finds it difficult to concentrate on information within paperwork. Due to her mental illness she experiences flatness & manic & has difficulty concentrating, understanding & remembering new things."]

[textarea cols=80 rows=20 default=""]

2.4 MOBILITY & TRANSPORT

Does the person require assistance for independent mobility because of their impairment/s?

[checkbox value="No, does not need assistance in this area.|Needs special equipment to move in or out of the home. This includes getting in and out of bed for example.|Needs assistive technology.|Needs home modifications.|Cannot use public transport, or experiences difficulty doing so.|Needs assistance from other persons, physical assistance, guidance, supervision or prompting within the home and leaving the home. This includes manual handling.|Needs assistance with travel and or transport. This includes mobility difficulties because of side effects of treatment.|Needs assistance with travel and or transport because they are reluctant to travel alone and or reluctant to travel to unfamiliar environments."]

-- Description of Area of Need --

[checkbox value="N/A|• Moving around the house|• Moving about in the community|• Volunteering|• Using public transport or a car|• Getting in & out of bed or a chair|• Difficulties as a result of side-effects of treatment"].

-- Factors of Illness that Create Difficulty --

[checkbox value="N/A|• Paranoia|• Anxiety|• Depression|• Obsessions"]

-- Functional Implications --

[checkbox value="N/A|• Unable to use public transport unaccompanied|• Difficulty leaving the house"]

-- Physical Health Implications --

[checkbox value="N/A|• Inability to get to medical appointments|• Inability to get scripts filled|• Inability to do appropriate food & hygiene shopping"]

-- Type of Support Needed --

[checkbox value="N/A|• Person to accompany when using public transport"]

-- Frequency of Support Needed --

Attend weekly activity ([checkbox value="0|1|2|3|4|5|6|7|8|9"] hr/wk).
Grocery shopping ([checkbox value="0|1|23|4|5|6|7|8"] hr/wk).
Appointments ([checkbox value="0|1|2|3|4|5|6|7|8|9"] hrs/mth).

Total [checkbox value="0|1|2|3|4|5|6|7|8|9|10|11|12|13|14|15|16|17|18|19|20"] hrs/mth

-- Example Observations --

[comment memo="X is unable to leave the house or use public transport on a daily basis as a direct result of her severe anxiety & lack of motivation which are symptoms of her mental illness. One-on-one support on a weekly basis would assist her to cope with her anxiety & improve her motivation assisting her to be more mobile."]

[textarea cols=80 rows=20 default=""]

2.5 SELF-CARE

Does the person require assistance to self- care because of their impairment/s?

[checkbox value="No, does not need assistance in this area.|Needs assistance to maintain a safe living environment.|Needs assistance to maintain physical health, including managing medication, sexual health and wellbeing.|Needs assistance for personal hygiene and have a regular routine in the home. This includes grooming, feeding, showering, dressing, eating, and toileting.|Needs assistance to do housework and gardening.|Needs special equipment, assistive technology and/or assistance from other people."]

-- Area of difficulty --

[checkbox value="N/A|• Showering/bathing|• Dressing|• Eating|• Toileting|• Maintaining physical health|• Managing medication"]

-- Factors of illness that create difficulty --

[checkbox value="N/A|• Medication side effects causing weight gain|• Increased appetite • Lethargy"]

-- Functional implications --

Difficulty with: [checkbox value="• Nothing of note|• Hygiene|• Maintaining adequate diet|• Nutrition|• Dressing appropriately|• Managing physical wellbeing|• Maintaining physical health"]

-- Physical health implications --

[checkbox value="N/A|• Good hygiene habits • Good nutrition & dietary management • Personal safety in the home eg. trip hazards"]

-- Type of support needed --

[checkbox value="No Support needed|Assist with equipment to enable self care activities|Access to healthy lifestyle activities including exercise"]

-- Frequency of support needed --

[checkbox value="N/A|Assistance to attend exercise program, including transport on weekly basis|Provision of equipment|training & support (6hrs/ mth) and equipment costs"]

-- Example Observations --

[comment memo="X presents as dishevelled with poor levels of hygiene. X has delusional beliefs associated with water. X manages her own meal preparation
by purchasing freezer meals, but often forgets to eat due to distracting symptoms
& does not shower regularly. X is unable to maintain cleanliness of her unit & reports that it is too much for her to manage on her own. X has lived in squalor
for the last 5 years."]

[textarea cols=80 rows=20 default=""]

2.6 SELF MANAGEMENT

Does the person require assistance to manage themselves because of their impairment/s?

[checkbox value="No, does not need assistance in this area.|Needs assistance to organise and coordinate their day-to-day life.|Needs assistance to manage diet and or nutrition and or go grocery shopping and or prepare own meals.|Needs assistance to make decisions and problem solve. This includes having difficulty coping with situations involving stress, pressure or performance demands.|Needs assistance to attend appointments and engage with other professionals.|Needs assistance to coordinate professional supports.|Needs assistance to manage their finances. This can include paying bills and budgeting money.|Needs special equipment, assistive technology and/or assistance from other people."]

-- Description of area of need --

[checkbox value="• Doing activities (e.g. cooking, laundry)|• Handling & solving problems|• Managing money|• Budgeting|• Making decisions|• Keeping safe in-home environment|• Taking responsibility|• Behaving responsibly|• Connecting to services"]

-- Factors of Illness that Create Difficulty --

[checkbox value="• Motivation|• Cognitive Difficulties|• Issues related to self awareness|• Compulsion|• Depression|• Preoccupations|• Hallucinations|• Anxiety|• Tangential thinking|• Paranoia"]

-- Functional Implications --

Difficulty with: [checkbox value="N/A|• Attending to responsibilities due to; lack of motivation, interest, concentration & organisation|• Managing household|• Budgeting|• Solving problems|• Making decisions"]

-- Physical Health Implications --

[checkbox value="N/A|• Scheduling appointments|• Connecting to services|• Financing health appointments & medication|• Management"]

-- Type of Support Needed --

[checkbox value="N/A|Person to supervise, support with care of house, managing money, getting services, etc."]

-- Frequency of Support Needed --

[comment memo="Assist with minimum 1 meal/ day & other home based responsibilities. Assist with shopping & appointments (3hrs/wk) Total 17 hrs/wk"]

[textarea cols=80 rows=20 default=""]

3.0 CONCLUDING STATEMENT

Other important information to consider or note:

[textarea default="N/A"]

Delete this paragraph if not applicable – Person’s name has a disability that is likely to be life long, reduces their functional capacity in their daily life, and or may benefit from early intervention to prevent or minimise the deterioration in their condition/s. Person’s name is likely to require assistance from the NDIS on an ongoing basis to effectively manage the impacts of their impairment/s.
If you have any questions related to any of the information stated above or you would like to discuss further, please do not hesitate to contact me.

Kind Regards,


[textarea default=""]
NDIS Access Request Report

Date:

To Whom It May Concern,

Re: Letter in support of NDIS Access Request for

I am assisting with requesting access to the National Disability Insurance Scheme (NDIS). This individual has been a patient of
Community Mental Health since for mental health treatment, and clinical care coordination.

My details are:

Clinician:
Professional qualification: .
Address:
Phone Number:
Fax:

1.0 DIAGNOSES

Diagnosis:
Date of Diagnosis:
Diagnosis Made By:
Is it likely to be permanent?

Please see supporting evidence relating to the diagnosis attached.

1.2 APPLICABLE DIAGNOSITC CATEGORIES:



1.3 APPLICABLE PROVISION OF EARLY INTERVENTION SUPPORTS:



If applicable, details of recommended early intervention supports:



1.4 BRIEF DESCRIPTION OF TREATMENT:

-- Past Treatments and Outcomes --

(previous medications, aids, protective equipment, and assistive technology)























-- Current Treatments --

(list current medication, aids and protective equipment and if these are expected to improve the symptoms or if they are for maintenance only)























-- Other Treatment Options --

Please list other treatment options not trialed and or considered. State the reason (e.g. medication interaction, impact of other impairments, affordability)

Other Treatment Options:

Reasons:

1.5 LEVEL OF IMPAIRMENT ASSESSMENTS

Assessment Type:
Date Completed:
Score or Rating Conclusion:

Please see assessment attached to this report.

2.0 FUNCTIONAL CAPACITY

Person’s name has substantial reduced functional capacity in the following domains because of their impairment/s:

2.1 COMMUNICATION

Does the person require assistance to communicate because of their impairment/s?

.

-- Description of area of need --



-- Factors of the illness that create difficulty --



-- Functional Implications --



-- Physical Health Implications --



-- Type of Support Needed --



-- Frequency of Support Needed --

Monthly support to attend appointments, weeky support to attend & participate in volunteer group



-- Example Observations --

X has become isolated in the community since being diagnosed with schizophrenia. X experiences symptoms of paranoia & therefore finds it difficult to interact with others, engage in volunteer or paid work & venture independently into the community. X struggles to follow directions & is easily distracted. X is fiercely independent & has limited insight into his ability to complete daily activities & as a result often fails to communicate his own needs for support.



2.2 SOCIAL INTERACTION

Does the person require assistance to interact with others because of their impairment/s?



-- Description of area of need --



-- Factors of illness that create difficulty --



-- Functional Implications --



-- Physical Health Implications --



-- Type of support needed --



-- Frequency of support needed --

Attendance at social activities ( hrs/wk) and graded support for new social situations.

-- Example Observations --

X has become socially isolated since being diagnosed with depression. X doesn’t venture into the community alone. X feels very anxious when meeting new people which further adds to his social isolation. X speaks very quickly due to mania, & is frequently unable to speak due to feeling depressed. It is very difficult for X to interact socially & maintain friendships. X has feelings & emotions she is unable to cope with due to her mental illness.



-- Assistance required --

.

If yes, please briefly explain the difficulties with social interaction:



2.3 LEARNING

Does the person require assistance to learn new skills because of their impairment/s?



-- Description of Need --



-- Factors of Illness that Creat Difficulty --



-- Functional Implications --

Difficulty with:

-- Physical Health Implications --



-- Type of Support Needed --

Equipment that assists with recording & organising (e.g. tablet device) Person to assist with learning & engaging in activities

•Needs assistance and equipment that assists with recording & organising (e.g. tablet device)|• Needs a support worker to assist with learning & engaging in activities



-- Frequency of Support Needed --

Support & training for device use (10hrs over 5 weeks) Assistance with study/rec activities (1hr/wk) Total 6hrs/mth + equipment cost



-- Example Observations --

X finds it difficult to concentrate on information within paperwork. Due to her mental illness she experiences flatness & manic & has difficulty concentrating, understanding & remembering new things.



2.4 MOBILITY & TRANSPORT

Does the person require assistance for independent mobility because of their impairment/s?



-- Description of Area of Need --

.

-- Factors of Illness that Create Difficulty --



-- Functional Implications --



-- Physical Health Implications --



-- Type of Support Needed --



-- Frequency of Support Needed --

Attend weekly activity ( hr/wk).
Grocery shopping ( hr/wk).
Appointments ( hrs/mth).

Total hrs/mth

-- Example Observations --

X is unable to leave the house or use public transport on a daily basis as a direct result of her severe anxiety & lack of motivation which are symptoms of her mental illness. One-on-one support on a weekly basis would assist her to cope with her anxiety & improve her motivation assisting her to be more mobile.



2.5 SELF-CARE

Does the person require assistance to self- care because of their impairment/s?



-- Area of difficulty --



-- Factors of illness that create difficulty --



-- Functional implications --

Difficulty with:

-- Physical health implications --



-- Type of support needed --



-- Frequency of support needed --



-- Example Observations --

X presents as dishevelled with poor levels of hygiene. X has delusional beliefs associated with water. X manages her own meal preparation
by purchasing freezer meals, but often forgets to eat due to distracting symptoms
& does not shower regularly. X is unable to maintain cleanliness of her unit & reports that it is too much for her to manage on her own. X has lived in squalor
for the last 5 years.




2.6 SELF MANAGEMENT

Does the person require assistance to manage themselves because of their impairment/s?



-- Description of area of need --



-- Factors of Illness that Create Difficulty --



-- Functional Implications --

Difficulty with:

-- Physical Health Implications --



-- Type of Support Needed --



-- Frequency of Support Needed --

Assist with minimum 1 meal/ day & other home based responsibilities. Assist with shopping & appointments (3hrs/wk) Total 17 hrs/wk



3.0 CONCLUDING STATEMENT

Other important information to consider or note:



Delete this paragraph if not applicable – Person’s name has a disability that is likely to be life long, reduces their functional capacity in their daily life, and or may benefit from early intervention to prevent or minimise the deterioration in their condition/s. Person’s name is likely to require assistance from the NDIS on an ongoing basis to effectively manage the impacts of their impairment/s.
If you have any questions related to any of the information stated above or you would like to discuss further, please do not hesitate to contact me.

Kind Regards,


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