DOCUMENT 4
Released by the NDIA on
Access Request Form
Complete this form to request to become a participant in the National Disability Insurance Scheme (NDIS).
You must provide proof of age, residence (including citizenship or visa status) and disability (or your need for early intervention supports) with this Access Request Form. We cannot make a decision on your access request without this information.
If you have questions about this form, need help to complete it or would like more information about the NDIS, please contact us:
Phone: 1800 800 110 | TTY: 1800 555 677 | Speak and Listen: 1800 555 727
Internet Relay: Visit http://relayservice.gov.au and ask for 1800 800 110 |
Email: NAT@ndis.gov.au
Part A: Your details (the person wishing to become an NDIS participant)
| Full name | Josephine Bloggs |
|---|---|
| Date of birth (DD/MM/YYYY) | 8 / 10 / 2010 |
| Gender | [ ] Male [x] Female [ ] Unspecified (X) |
| Are you of Aboriginal or Torres Strait Islander origin? | [x] No [ ] Yes - Aboriginal [ ] Yes - Torres Strait Islander [ ] Yes - Aboriginal and Torres Strait Islander [ ] Do not wish to disclose |
| Country of birth | Australia |
| Language spoken at home | English |
| Are you living in Australia permanently? | [x] Yes [ ] No |
| Current home address | 123 Orange Street Appletown State: NSW Postcode: 1234 |
| Postal address If different to current home address: |
[x] As above State: Postcode: |
| For Western Australia or Northern Territory only: What was your home address on 1 July 2014? If different: |
[ ] Same as current home address above State: Postcode: |
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| Are you an Australian Citizen? | [x] Yes [ ] No |
|---|---|
| If NO, what type of visa do you have? | [ ] Permanent visa [x] Protected special category visa. [ ] Other including temporary visa (please specify below) Visa Type: ________________________ Nationality: ________________________ Passport Number: ________________________ |
Part B: Your privacy and consent to collect and share your information
The National Disability Insurance Agency (NDIA) collects personal information to help us determine whether you can access the NDIS. As a participant, the NDIA will also collect and use your information to help develop and implement your NDIS Plan and do other things related to the NDIS.
In addition to collecting certain information from you, we may contact your service providers, health and medical practitioners and other government agencies to request the provision of personal and health information about you which will help us to determine whether you meet the access requirements for the NDIS and, if so, to provide supports to you under the NDIS.
If you live in Shared Supported Accommodation, (e.g. a home shared with other people with disabilities that includes shared support from paid staff), we may also disclose your personal information to personnel employed within the group home to enable the Agency to collect further personal information about you in order to support the development of your NDIS plan if you become a participant.
Please note that if you do not consent to the collection of your personal information, the NDIA may not be in a position to determine whether you meet the access requirements for the NDIS or develop your NDIS Plan if you become a participant. More information about the collection, use, disclosure and storage of your personal information by the NDIA can be accessed on our online Privacy Notice and Privacy Policy at www.ndis.gov.au/privacy or by contacting the NDIA.
| Do you consent to the NDIA collecting your information including from these third parties, for the purposes of determining whether you meet the access requirements for the NDIS and to help develop or implement your NDIS Plan if you become a participant. | [x] Yes, I consent [ ] No, I do not consent. |
You can give us consent to obtain information about your age, disability, and residence from Centrelink (below) or you can provide us with certified copies of the required documents yourself. We cannot make a decision without this information.
| The Australian Government Department of Human Services (including Centrelink and Medicare) | [x] Yes, I consent [ ] No, I do not consent.
My CRN is: ___________________ [ ] I will provide the information myself. |
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Part C: How would you like NDIA to contact you?
| [ ] Home phone | TTY: |
| [x] Mobile phone | 0400 000 000 |
| emailaddress@outlook.com | |
| [ ] Other (please specify): | |
| How would you like to receive letters? | [ ] Email [x] Post |
| Do you need an interpreter to help us talk with you? | [x] No [ ] Yes Language: _________________ |
| [x] Do not contact me directly | [x] Contact my parent/legal guardian or representative (Part D) [ ] Other (please specify): _________________ |
Part D: Parent, legal guardian or representative details (if applicable)
Complete this section if you are filling out this form for:
- a person aged under 18 for whom you have parental responsibility, OR
- a person for whom you are a representative or a legal guardian
You do not need to complete this section if you are just helping the person fill out this form.
| Full name | Jasmine Bloggs |
|---|---|
| Relationship to person making request: | Mother |
NOTE: If you are a legally appointed guardian you will need to provide your Proof of Identity (POI) and guardianship status to the NDIA. This information can be verified through the Australian Department of Human Services (Centrelink) using the CRN provided on page 2 (if applicable) or you can provide copies of two POI documents (or a ‘Government issued photo card’) and the guardianship document with this form.
| Phone | 0400 000 000 TTY: |
|---|---|
| How would you like to receive letters? | |
| [x] Email | emailaddress@outlook.com |
| [ ] Post | [x] Same as person making request If different: |
State: Postcode: |
| Do you need an interpreter? | [x] No
[ ] Yes Language: _________________ |
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Part E: Information about your carers and family members (if applicable)
| My Carer’s full name: | Jasmine Bloggs |
|---|---|
| Contact phone number: | 0400 000 000 TTY: |
| Will your carer be taking part in the planning conversation? | [x] Yes [ ] No |
| Do you have another family member who is, or is seeking to become a NDIS participant? | [ ] Yes [x] No If yes please provide their name: ________________________ |
Part F: Your disability, or need for early intervention supports
So we can determine whether you (or your child) meet the disability or early intervention access requirements (including developmental delay), you need to provide us with information about your disability or impairment.
| Primary disability: (This is the disability that has the most impact on your daily life) |
Autism |
|---|---|
| Please list other disabilities (if any): |
Not Applicable |
| Did you acquire your disability because of an injury? | [ ] Yes [x] No |
| Are you seeking, or have you previously sought compensation related to your disability or injury? | [ ] Yes [x] No |
If you have undertaken one or more of the following assessments or reports in relation to your disability, please provide a copy with your Access Request Form:
- The Care and Needs Scale (CANS)
- Vineland Adaptive Behaviour Scales, 2nd Ed (Vineland-II)
- Diagnostic and Statistical Manual of Mental Disorders, 5th Ed (DSM-5) — Autism Spectrum Disorder
- Diagnostic and Statistical Manual of Mental Disorders, 4th Ed (DSM-4) — Autism Spectrum Disorder
- Childhood Autism Rating Scale (CARS)
- Adaptive Behaviour Assessment System (ABAS)
- Autism Diagnostic Observation Schedule (ADOS)
- Gross Motor Functional Classification Scale (GMFCS)
- Communication Function Classification Score (CFCS)
- Manual Ability Classification System (MACS)
- Diagnostic and Statistical Manual of Mental Disorders, 5th Ed (DSM-5) — Intellectual Disability
- Diagnostic and Statistical Manual of Mental Disorders, 4th Ed (DSM-4) — Intellectual Disability
- Clinical Evaluation of Language Fundamentals, 4th Ed
- Wechsler Preschool and Primary Scale of Intelligence, 3rd Ed (WPPSI-III)
- Wechsler Intelligence Scale for Children (WISC-IV)
- IQ test
- Hearing Loss (Measured in decibels in better ear)
- Disease Steps
- Expanded Disability Status Scale
- Level of lesion
- ASIA Score
- Modified Rankin Scale
- Visual acuity level
- Visual field loss (horizontal and vertical)
- World Health Organisation Disability Assessment Schedule (WHODAS 2.0)
- Other
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We need supporting information about your disability and the impact it has on your mobility, communication, social interaction, learning, self-care and/or ability to self-manage.
You can do this by:
[ ] Providing us with copies of reports, letters or assessments from your health or education professional detailing your (or your child’s) impairment and the impact it is has on daily life
OR
[x] By asking a professional to complete the table below:
| Full name of professional (health or education) | Dr. James |
|---|---|
| Professional Qualification | General Practitioner |
| Phone | |
| Length of time you have known or treated the person making request? | 10 years - Family Doctor |
| Primary disability and any secondary disabilities: | Autism |
| Current treatment (if any): | Not engaged |
| Is there any other treatment that is likely to remedy the impairment? | [x] Yes [ ] No Psychologist, Occupational Therapist and Speech Pathology required. |
1. Mobility/motor skills
Moving around the home (crawling/walking), getting in or out of bed or a chair, leaving the home and moving about in the community
Assistance required does not include commonly used items such as glasses, walking sticks, non-slip bath mats, bathroom grab rails and hand rails installed at stairs
[x] 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)
If yes, please describe the type of assistance required:
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2. Communication
Being understood in spoken, written or sign language, understanding others and express needs and wants by gesture, speech or context appropriate for age
[ ] No, does not need assistance [ ] Yes, needs special equipment [ ] Yes, needs assistive technology [x] Yes, needs assistance from other persons: (physical assistance, guidance, supervision or prompting)
If yes, please describe the type of assistance required: Only speaks to people that she knows well and only things she is interested in Cannot communicate feelings
3. Social interaction
Making and keeping friends, interacting with the community (or playing with other children), coping with feelings and emotions
[ ] No, doés not need assistance [ ] Yes, needs special equipment [ ] Yes, needs assistive technology [x] Yes, needs assistance from other persons: (physical assistance, guidance, supervision or prompting)
If yes, please describe the type of social interaction assistance required: Does not actively engage in activities Limited social interaction Parallel play
4. Learning
Understanding and remembering information, learning new things, practising and using new skills
[ ] No, does not need assistance [ ] Yes, needs special equipment [ ] Yes, needs assistive technology [x] Yes, needs assistance from other persons: (physical assistance, guidance, supervision or prompting)
If yes, please describe the type of assistance required: Teacher’s aide
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5. Self-Care
Showering/ bathing, dressing, eating toileting, caring for own health (not applicable for children under two years of age)
Assistance required does not include commonly used items such as non-slip bath mats, bathroom grab rails and hand rails installed at stairs
[ ] No, do not need assistance [ ] Yes, need equipment/ assistive technology [x] Yes, need assistance from another person in the areas of:
[x] showering/bathing [ ] eating/drinking [ ] overnight care (e.g. turning) [x] toileting [x] dressing
If yes, please describe the type of assistance required: Prompting and reminding to wear appropriate clothing Does not like certain fabrics
6. Self-Management
Doing daily jobs, making decisions and handling problems and money (not applicable for children under 8 years of age)
[ ] No, does not need assistance [ ] Yes, needs special equipment [ ] Yes, needs assistive technology [x] Yes, needs assistance from other persons: (physical assistance, guidance, supervision or prompting)
If yes, please describe the type of assistance required:
| Signature of Professional | [Signature icon] | Date | 18 / 4 / 20 20 |
|---|
Part G: Change of circumstances
The law requires you to tell the NDIA if a change of circumstances happens (or is likely to happen) that might affect your request to be a participant in the NDIS or, if you become a participant, that might affect your status as a participant or your NDIS Plan.
For example, you must tell us if your disability support needs change, you move house or overseas, or receive compensation relating to an injury.
You must tell us as soon as you reasonably can. You can do this in person, over the telephone or by letter, email or fax.
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Part H: Signature
When I sign this Access Request Form:
- I certify that the information I have provided is true and correct and that I have given all of the information and documents that I have or can get that are required by this Access Request Form
- I understand that giving false or misleading information is a serious offence.
- I understand that I am giving consent for the NDIA to do the things with my information set out in Part B and with the people I have indicated in Part D. I understand that I can withdraw my consent for the NDIA to do things with my information at any time by letting the NDIA know.
- I understand that I can access the NDIA’s Privacy Notice and Privacy Policy on the NDIA website or by contacting the NDIA.
- I understand that if I have selected email under Part C as my preferred means of communication, that the NDIA may email me sensitive or confidential information. I understand that the NDIA cannot guarantee the security of the email once it leaves the NDIA system.
- I understand that my access to the following Commonwealth programs will cease (if applicable) if I become a participant in the NDIS:
- Helping Children with Autism and Better Start
- Mobility Allowance
Signature: J Bloggs Date: 27 / 4 / 20 20
Full Name (please print): Jasmine Bloggs
If you have signed this Access Request Form on behalf of the person wishing to become an NDIS participant please complete the details below. It is an offence to provide false or misleading information.
Full name of person completing this form (please print): Jasmine Bloggs
Relationship to person wishing to become an NDIS participant: Mother
We may require you to provide evidence of your authority to sign on behalf of the person.
Please return the completed form to:
Mail: GPO Box 700, Canberra, ACT 2601
Email: NAT@ndis.gov.au or
In person: take it to your local NDIA office
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Access Request — Supporting Evidence Form
The National Disability Insurance Agency (NDIA) will use the information in this form to determine if a person meets the requirements to become a participant in the National Disability Insurance Scheme (NDIS). For children under 6 with a developmental delay, please use the Access Request — Supporting Evidence Form for Children Under 6 with Developmental Delay.
| Instructions for the person applying to become a participant in the NDIS | Instructions for the health or educational Professional completing this form |
|---|---|
| You do not need to complete this form if you can provide recent existing information (letters, assessments or other reports) from a health or education professional which details: - your impairment; - how long it will last; and - how it impacts on your daily life. How to complete this form: Section 1 can be completed by you, your parent, representative or your health or educational professional. Sections 2 and 3 must be completed by a health or educational professional. |
Sections 2 and 3 of this form must be completed by a health or education professional. You may provide the person applying to the NDIS with copies of letters, assessments or other reports in lieu of completing this form. If you have any questions about this form please contact the NDIA on 1800 800 110 or go to ndis.gov.au |
If you have questions about this form, are having difficulty completing it, or would like more information about the NDIS, please contact us:
Phone: 1800 800 110 | TTY: 1800 555 677 | Speak and Listen: 1800 555 727
Internet Relay: Visit http://relayservice.gov.au and ask for 1800 800 110
Email: nationalaccessteam@ndis.gov.au
Returning this form:
Please return the completed form to:
Mail: GPO Box 700, Canberra, ACT 2601
Email: NationalAccessTeam@ndis.gov.au
Or take it to your local NDIA office.
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SECTION 1: Details of the person applying to become a participant in the NDIS
This part of the form can be completed by you, a parent, representative or professional
| Full name | Josephine Bloggs |
|---|---|
| Date of Birth | 08/10/2010 |
| Name of parent/ guardian/ carer/ representative | Jasmine Bloggs |
| Phone | 0400 000 000 |
| NDIS number (if known) |
SECTION 2: Details of the person’s impairment/s
This part of the form must be completed by a treating doctor or specialist
1. Details of the health professional completing Section 2
| Full name of health professional | Helen Smith |
|---|---|
| Professional Qualification | Registered Psychologist |
| Address | Appletown |
| Phone | |
redacted |
|
| Signature | H. Smith |
| Date | 28/04/2020 |
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2. Details of the person’s impairment/s
| 2.1 What is the person’s primary impairment (i.e. the impairment with the most impact on daily life)? | Autism Spectrum Disorder |
|---|---|
| 2.2 How long has the person had this impairment? | Diagnosed in November 2019 |
| 2.3 Is the impairment likely to be lifelong? NB: an impairment may be considered likely to be lifelong even if the impact on the functional capacity fluctuates or varies in intensity over time. |
No - needs to be engaged with allied health professionals |
| 2.4 Please provide a brief description of any relevant treatment undertaken (current and/or past) | Nil treatment undertaken due to financial constraints. Needs to be engaged with a Psychologist, Occupational Therapist and Speech Pathologist |
| 2.5 Does the person have another impairment that has a significant impact? If yes, please list | Not Applicable |
| 2.6 How long has the person had this impairment? | Not Applicable |
| 2.7 Is the impairment likely to be lifelong? | Not Applicable |
| 2.8 Please provide a brief description of any relevant treatment undertaken (current and/or past) | Not Applicable |
| 2.9 Does the person have any other impairments? If yes, please list | Not Applicable |
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3. Are there early intervention supports that are likely to benefit the person by reducing their future needs for supports? If yes, please tick and write details. If no proceed to question 4.
| The provision of early supports will: Please tick [x] [x] Alleviate the impact on functional capacity [x] Prevent deterioration of functional capacity [x] Improve functional capacity [x] Strengthen the sustainability of available or existing supports |
Details of recommended early intervention supports: Psychology - weekly to improve social skills and anxiety Occupational Therapy - help improve fine motor skills and sensory seeking behaviour Speech Therapy - required to improve speech and language delay |
|---|
4. Have any assessments been undertaken of the person’s impairment(s)? If yes, please write details and tick if assessment is attached to form. If no proceed to SECTION 3.
Please record assessment type, the date the assessment was undertaken and the assessment score or rating
| Assessment Type* | Date Completed | Score or Rating | Assessment attached to this form? |
|---|---|---|---|
| Care and Need Scale (CANS) | [ ] Yes [ ] No | ||
| Gross Motor Functional Classification Scale (GMFCS) | [ ] Yes [ ] No | ||
| Hearing Acuity Score | [ ] Yes [ ] No | ||
| Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) | 25/11/2019 | Lvl 1 | [ ] Yes [x] No |
| Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-4) | [ ] Yes [ ] No | ||
| Visual Acuity Rating | [ ] Yes [ ] No | ||
| Communication Function Classification System (CFCS) | [ ] Yes [ ] No | ||
| Vineland Adaptive behaviour Scale (Vineland-II) | [ ] Yes [ ] No | ||
| Modified Rankin Scale (mRS) | [ ] Yes [ ] No | ||
| Manual Ability Classification Scale (MACS) | [ ] Yes [ ] No | ||
| American Spinal Injury Association Impairment Scale (ASIA/AIS) | [ ] Yes [ ] No | ||
| Disease Steps | [ ] Yes [ ] No | ||
| Expanded Disability Status Scale (EDSS) | [ ] Yes [ ] No | ||
| Other………………………………………………………………………… | [ ] Yes [ ] No |
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SECTION 3: Details of the functional impact of the impairment/s
This part of the form must be completed by a health or education professional
You can provide an existing report instead of completing this Section, however it is important that the information you provide matches the information required by this Section.
1. Mobility
Moving around the home, getting in and out of bed or a chair, mobilising in the community including using public transport or a motor vehicle.
- Assistance required does not include commonly used items such as glasses, walking sticks, non-slip bath mats, bathroom grab rails and hand rails installed at stairs.
| Does the person require assistance to be mobile because of their impairment/s? | [ ] Yes, needs special equipment
[ ] Yes, needs assistive technology
[ ] Yes, needs home modifications
[ ] Yes, needs assistance from other persons (including physical assistance, guidance, supervision or prompting) |
| [x] No, does not need assistance | |
If yes, please describe the type of assistance required:
2. Communication
Being understood in spoken, written or sign language and ability to understand language and express needs and wants by gesture, speech or context appropriate for age.
| Does the person require assistance to communicate because of their impairment/s? | [ ] Yes, needs special equipment
[ ] Yes, needs assistive technology
[ ] Yes, needs home modifications
[x] Yes, needs assistance from other persons (including physical assistance, guidance, supervision or prompting) |
| [ ] No, does not need assistance | |
If yes, please describe the type of assistance required: Josephine will only talk about topics that she is interested in and to people that she is familiar with. She appears to have a speech and language delay and will need to engage with a speech pathologist to improve this.
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3. Social interaction
Making and keeping friends and relationships, behaving within limits accepted by others, coping with feelings and emotions.
| Does the person require assistance to interact socially because of their impairment/s? | [ ] Yes, needs special equipment
[ ] Yes, needs assistive technology
[x] Yes, needs assistance from other persons: (including physical assistance, guidance, supervision or prompting) |
| [ ] No, does not need assistance | |
If yes, please describe the type of social interaction assistance required: Josephine has limited social interaction due to communication barriers. She would benefit from attending the Secret Agent Society program to improve social skills and reduce her anxiety in these situations.
4. Learning
Understanding and remembering information, learning new things, practicing and using new skills
| Does the person require assistance to learn effectively because of their impairment/s? | [ ] Yes, needs special equipment
[ ] Yes, needs assistive technology
[ ] Yes, needs assistance from other persons: (including physical assistance, guidance, supervision or prompting) |
| [x] No, does not need assistance | |
If yes, please describe the type of assistance required:
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5. Self-Care
Showering/ bathing, dressing, eating, toileting, caring for own health.
- Assistance required does not include commonly used items such as non-slip bath mats, bathroom grab rails and hand rails installed at stairs.
| Does the person require assistance with self-care because of their impairment/s? | [ ] Yes, need special equipment
[ ] Yes, needs assistive technology
[ ] Yes, needs home modification
[x] Yes, needs assistance from other persons in the areas of: |
| [ ] No, does not need assistance | [x] showering/bathing [x] toileting
[x] eating/drinking [x] dressing
[ ] overnight care (e.g. turning) |
If yes, please describe the type of assistance required: Josephine has sensory seeking behaviours and doesn’t always like the feel of the shower water on her. It would be beneficial that she engage with an Occupational Therapist to address these concerns
6. Self-Management
Doing daily jobs, making decisions and handling problems and money (not applicable for children under 8 years of age)
| Does the person require assistance with self-management because of their disability? | [ ] Yes, needs special equipment
[ ] Yes, needs assistive technology
[ ] Yes, needs assistance from other persons: (physical assistance, guidance, supervision or prompting) |
| [x] No, does not need assistance | |
If yes, please describe the type of assistance required:
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