MDSS Occupational Therapy Intake Form

Occupational Therapy Intake Form
Mildura Disability Support Services - ABN 61 684 083 574

Please note: MDSS Occupational Therapy currently only accepts referrals for clients accessing services through the NDIS or Home Care Packages. At this time, we are unable to accept private clients or referrals outside of these. If you have any questions or concerns, please do not hesitate to get in touch.

Which service(s) are you seeking? *

Occupational TherapyAllied Health Assistant

Client Name *

Date of Birth *

Address *

Phone number *

Email Address *

Occupation - if none type NA *

Preferred Method of Contact *

PhoneTextEmail

Emergency Contact:

Name *

Relationship *

Phone number *

Reference Number eg NDIS number etc *

Is the client Plan Managed or Self-Managed? (We do not accept OT referrals for NDIA-managed participants) *

Plan ManagedSelf-Managed

Please provide your Plan Manager's Name (if applicable) *

Please provide a billing email: *

Support Coordinator Name and Email address if applicable

Funding Source *

NDISHome Care Package

For NDIS or Home Care Package, what is your Support Coordinator's name and contact details:

What type of service are you requiring? *

What specific funding is allocated to these services? *

Please Provide NDIS Plan Dates If Applicable *

The Functional Capacity Assessment requires a number of self-assessment tools to be completed. Are you able to complete these yourself, or would you prefer to have support?

I can complete myselfI would like support

Please upload a copy of the NDIS plan if appropriate

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Referral Information *

GPSupport CoordinatorSelfOther

Primary Diagnosis/Reason for Referral *

If ticked one of the above, please provide more details:

Please upload any relevant medical or allied health reports (paediatrician, psychologist, previous occupational therapy assessments, speech pathology)

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Allergies? If none, type NA.

Will a support worker attend the sessions?

YesNoOther

Support Worker organisation details

If this is a self referral, I give permission Aus Disability Support to share relevant reports, information and updates with:

NDIS Goal Alignment - Participant Goals from NDIS Plan. Please list. If not NDIS please type NA *

Where are the sessions to be held if not at the Occupational Therapy Office?

If self referral, I consent to Aus Disability Support Pty Ltd collecting and storing my personal and medical information for the purpose of providing allied health services. I understand my information will be kept confidential and only shared with relevant professionals involved in my care as required.

Signature of person completing the form *

Draw signature|Type signatureClear

Name of person completing the form *

Relationship to client - if self, type NA *

Date *

Version: 1
Last updated: 31/08/26