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Occupational Therapy Specialist
10-15 minutes

Application Form for NDIS Assistive Technology

The s10.ai Assistive Technology Application Form is an essential tool for occupational therapists and healthcare professionals dedicated to aiding individuals with disabilities. This template streamlines the application process for assistive technology funding under the National Disability Insurance Scheme (NDIS), featuring sections for participant information, technology specifications, supplier details, and expert recommendations. Utilizing this template ensures thorough and precise submissions, increasing the chances of approval for vital assistive devices. This form is pivotal in enhancing patient mobility, independence, and overall quality of life.

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Dr. Emily Carter
Template Structure

Organized sections for comprehensive clinical documentation

s10.ai Assistive Technology Request Form
Participant Details:
- Name: [Participant's Full Name] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- NDIS Number: [NDIS Number] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- Date of Birth: [Date of Birth] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- Address: [Participant's Address] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- Contact Number: [Contact Number] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- Email: [Email Address] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Support Coordinator/Plan Manager Details (if applicable):
- Name: [Support Coordinator/Plan Manager's Name] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- Organisation: [Organisation Name] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- Contact Number: [Contact Number] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- Email: [Email Address] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Assistive Technology Details:
- Type of Assistive Technology: [Type of Assistive Technology] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- Purpose of Assistive Technology: [Purpose of Assistive Technology] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- How will this Assistive Technology help the participant achieve their goals?: [Description of how the Assistive Technology will help] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Supplier Details:
- Supplier Name: [Supplier Name] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- Contact Person: [Contact Person] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- Contact Number: [Contact Number] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- Email: [Email Address] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- Address: [Supplier Address] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Quote Details:
- Item Description: [Item Description] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- Cost: [Cost] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- Delivery Timeframe: [Delivery Timeframe] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Health Professional Details:
- Name: [Health Professional's Name] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- Profession: [Profession] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- Registration Number: [Registration Number] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- Contact Number: [Contact Number] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- Email: [Email Address] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- Address: [Health Professional's Address] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Health Professional's Recommendation:
- Description of Participant's Disability: [Description of Participant's Disability] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- How the Assistive Technology will support the participant's needs: [Description of how the Assistive Technology will support the participant's needs] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- Any additional comments or recommendations: [Additional comments or recommendations] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Participant's Declaration:
- I declare that the information provided in this application is true and correct to the best of my knowledge.
- Signature: [Participant's Signature] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- Date: [Date] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Health Professional's Declaration:
- I declare that the information provided in this application is true and correct to the best of my knowledge.
- Signature: [Health Professional's Signature] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- Date: [Date] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Sample Clinical Note

Example of completed documentation using this template

NDIS Assistive Technology Application Form
Participant Details:
- Name: John Doe
- NDIS Number: 123456789
- Date of Birth: 01/01/1980
- Address: 123 Main Street, Springfield
- Contact Number: 0400 123 456
- Email: johndoe@example.com
Support Coordinator/Plan Manager Details (if applicable):
- Name: Jane Smith
- Organisation: Care Support Services
- Contact Number: 0400 654 321
- Email: janesmith@caresupport.com
Assistive Technology Details:
- Type of Assistive Technology: Electric Wheelchair
- Purpose of Assistive Technology: To improve mobility and independence
- How will this Assistive Technology help the participant achieve their goals?: The electric wheelchair will allow John to move independently within his home and community, enhancing his quality of life and enabling him to engage in social activities.
Supplier Details:
- Supplier Name: Mobility Aids Co.
- Contact Person: Mark Johnson
- Contact Number: 0400 789 012
- Email: mark.johnson@mobilityaids.com
- Address: 456 Elm Street, Springfield
Quote Details:
- Item Description: Electric Wheelchair Model X
- Cost: $5,000
- Delivery Timeframe: 2 weeks
Health Professional Details:
- Name: Dr. Emily Brown
- Profession: Occupational Therapist
- Registration Number: OT123456
- Contact Number: 0400 987 654
- Email: emily.brown@s10.ai
- Address: 789 Oak Avenue, Springfield
Health Professional's Recommendation:
- Description of Participant's Disability: John has a spinal cord injury resulting in restricted mobility.
- How the Assistive Technology will support the participant's needs: The electric wheelchair will provide John with the essential support to navigate his surroundings safely and independently.
- Any additional comments or recommendations: It is advised that John undergoes training on the use of the electric wheelchair to optimize its benefits.
Participant's Declaration:
- I declare that the information provided in this application is true and correct to the best of my knowledge.
- Signature: John Doe
- Date: 10/10/2023
Health Professional's Declaration:
- I declare that the information provided in this application is true and correct to the best of my knowledge.
- Signature: Dr. Emily Brown
- Date: 10/10/2023
Clinical Benefits

Key advantages of using this template in clinical practice

  • The NDIS Assistive Technology Application Form is an essential tool for healthcare professionals and participants seeking to enhance their quality of life through tailored assistive technology solutions. This comprehensive template captures critical participant details, including NDIS number and contact information, ensuring seamless communication and processing. It also facilitates collaboration with support coordinators and plan managers, detailing the type and purpose of the assistive technology, and how it aligns with the participant's goals. Supplier and quote details are meticulously documented to streamline procurement, while health professional recommendations provide expert insights into the participant's needs and the technology's impact. This form is designed to ensure accuracy and compliance, encouraging healthcare providers to adopt and implement it for efficient and effective NDIS applications.
Frequently Asked Questions

Common questions about this template and its usage

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