NDIS SERVICE REQUEST

Preferred Practice Location

Please Select The Participants Preferred Practice To Receive Supports From *

Client Details

First Name *

Last Name *

Date of Birth *

Phone Number *

Email Address

Street Address *

City *

State *

Postcode *

Client Representative Details (If Applicable)

First Name

Last Name

Phone Number

Email

Street Address

City

State

Postcode

NDIS Details

Plan *

Plan Managed Self Managed Agency Managed

Plan Manager Agency (If Applicable)

NDIS Number *

Email Address For Payment of Accounts (for Plan Managed Participant)

Available/Remaining Funding for Capacity Building Supports

Plan Start Date *

Plan Review Date *

Client Goals (As stated in the NDIS plan) *

Referrer Details (Person Making the Request)

First Name *

Last Name *

Agency

Role

Email Address *

Phone Number *

I have obtained consent from the participant to make this request and provide Core Physiotherapy & PIlates Studio with the participant's personal and medical details. *

Reason For Request

Referred For *

In Clinic PhysiotherapySupervised Exercise ProgramHydrotherapyHome Visit

Will a carer/support person be attending With The Participant? *

Is the client able to mobilise independently (walking, transfers from sit to stand etc)? *

Reason For Referral/Relevant Medical Information *

Supports Required

Please tick the following statements to acknowledge you have read and understand before proceeding.

The current rate NDIS Gazetted Support Rate for Physiotherapy in South Australia is $224.62/ hour, please detail below number, duration and frequency of sessions based on Participants needs and Funding available.

All initial appointments are based on a 1 Hour session duration to ensure adequate time to obtain history and baseline assessment information.

Travel Time to and from the practice needs to be accounted for with home visits, at the NDIS Gazetted hourly rate ($224.6/hour).

Reports will typically require an additional 1-2 hours of time per report if required, so please consider in budgeting if required.

If you are unsure of totals required a provisional service agreement can be arranged to enable an initial assessment to be completed and individual plan to be negotiated between the Participant and Physiotherapist).

Please Indicate Frequency Of Sessions Required *

Please Indicate Preferred Session Duration *

Please Indicate Total Number Of Sessions Required *

Please add any further details/comments below

Please attach a copy of the current NDIS Plan

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On submitting this request Core Physiotherapy & Pilates Studio will endevour to review the request details and arrange an NDIS Service Agreement to send to the Participant and Requesting Person for approval within 2 business days.

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