Evidence of Disability Report
To: National Disability Insurance Agency GPO Box 700 Canberra ACT 2600
Re: Thank you for considering this person for inclusion in the National Disability Insurance Scheme. I am a Medical Practitioner who currently provides them with psychiatric care.
This person experiences severe and permanent mental illness and has been diagnosed with the following condition(s),
Primary: Secondary:
The psychiatric illness(es) has resulted in a range of impairments that substantially and permanently reduce their ability to function. The following aspects of this person’s function are ‘impaired’ due to their illness (please tick):
- thoughts movements ‘energy’ levels
- mood perception judgement
- cognition/memory/concentration motivation sleep
- speech/language behaviour other:
The impact of the illness upon this person’s ability to function in everyday life is provided in the attached Report, ‘Evidence of Disability’, which is contained overleaf.
It is my professional opinion that the severity, enduring nature and functional impact of the illness meet the requirements for a ‘psychosocial disability’, as outlined in the National Disability Insurance Scheme Act (2013).
This person and I also feel that participation with the National Disability Insurance Scheme will assist them to better manage the impact of the mental illness and so enhance their quality of life.
We look forward to your response, Kind Regards,
Name: Medical Title: Organisation: Contact:
Disclaimer: This document has been developed by Health Directorate, Mental Health, Justice Health, Alcohol & Drug Services specifically for its own use. Use of this document and any reliance on the information contained therein by any third party is at his or her own risk and Health Directorate assumes no responsibility whatsoever.
EVIDENCE OF DISABILITY
(To be completed by relevant Doctor and/or Community staff)
PERSON’S NAME (applicant): DATE OF BIRTH:
IS IT LIKELY THAT THE FUNCTIONAL ‘IMPAIRMENTS’ (see previous) WILL BE PERMANENT? YES NO
DO THE RESULTING FUNCTIONAL ‘IMPAIRMENTS’ (see previous) SUBSTANTIALLY REDUCE THE PERSON’S YES NO CAPACITY TO PERFORM VARIOUS DAILY ACTIVITIES?
DO THE RESULTING FUNCTIONAL ‘IMPAIRMENTS’ (see previous) SUBSTANTIALY AFFECT THE PERSON’S YES NO cAPACITY FOR SOCIAL OR ECONOMIC PARTICIPATION?
IS IT LIKELY THAT THE ‘IMPAIRMENTS’ (see previous) WILL PERMANENTLY REDUCE THIS PERSON’S CAPACITY YES NO tO FUNCTION?
PLEASE DESCRIBE ASSISTANCE PROVIDED TO THIS PERSON BY THE ORGANISATION THAT YOU REPRESENT:
IS THIS PERSON ALSO PROVIDED ‘HEALTH CARE’ ASSISTANCE BY ACT GOVERNMENT DIRECTORATE MENTAL YES NO HEALTH SERVICES? Name of service(s):
Nature of assistance (please tick all):
Psychiatric support Case management Other:
IS THIS PERSON PROVIDED SUPPORT BY FAMILY MEMBERS AND/OR FRIENDS TO ASSIST THEM TO MANAGE YES NO N/A THE IMPACT OF THE CONDITION(S) ON THEIR DAILY FUNCTION? Please indicate person(s) and nature of assistance:
OTHER THAN THE ORGANISATION THAT YOU REPRESENT, IS THIS PERSON CURRENTLY RECEIVING OR HAVE YES NO THEY PREVIOUSLY BEEN PROVIDED, ASSISTANCE BY COMMUNITY ORGANISATION(S) AND/OR PROGRAMME(S) TO MANAGE THE IMPACT OF THE CONDITION(S) UPON THEIR DAILY FUNCTION? eg. PHaMS, Partners in Recovery, GP, Pharmacy assistance (eg. Webster packs), private counselling, accommodation, transport advocacy, personal support, social/support groups, supported decision making, employment assistance
Please list organisation(s) and nature of assistance:
IS IT LIKELY THIS PERSON WILL PERMANENTLY REQUIRE ASSISTANCE FROM COMMMUNITY ORGANISATIONS YES NO SUCH AS YOURS TO EFFECTIVELY MANAGE THE IMPACT OF THE CONDITION(S) ON THEIR DAILY FUNCTION?
Person’s name:
Which areas of this person’s daily function are Substantially and Permanently reduced due to the impact of the mental illness (please tick and circle all applicable):
SELF CARE Managing day-to-day personal care activities eg. showering, dressing, grooming, cooking, dental care
Managing own mental health care needs
eg. remembering medications, attending appointments, completing scripts
Managing own Physical Health care needs
eg. maintaining personal hygiene, managing health conditions,
Remaining safe throughout the day
eg. avoiding hazardous situations in home/community avoiding criminal behaviour, falls risk,
safe 'drinking/drug use'
SELF MANAGEMENT Maintaining Personal Goals and Direction in life eg. achieving goals, going on holidays, pursuing a career, having a sense of purpose
Completing Household Responsibilities
eg. cleaning, gardening, home maintenance, going shopping, paying rent
Maintaining employment, education and/or training roles
Remaining motivated and able to do interests and hobbies
Successfully managing own finances
eg. paying bills, saving money
Organising own daily routine
eg. getting places on time, arranging activities to do, decision making, remembering
SOCIAL INTERACTION Maintaining a productive Relationship with Family eg. family contact & support, maintaining relationship with your partner, completing parenting tasks
Maintaining a productive Relationship with Friends/acquaintances
eg. maintaining contact with friends, attending social events
Participating effectively in the community
eg. engaging in community groups, behaving appropriately in public, following directions
COMMUNICATION Expressing and understanding using speech and language
Expressing and understanding using non-verbal communication
LEARNING Adjusting to ‘Change’ and ‘Life Stressors’ eg. moving house, starting a new job, meeting new Doctor, a friend dying
Developing new skills for living independently
MOBILITY Accessing the community eg. driving a vehicle, catching public transport Managing physical tasks eg. walking, sitting for periods, lifting objects, standing, balance
Person’s name:
Nature of ‘assistance’ required (or predicted) for this person to reasonably perform those daily activities that are Substantially and Permanently reduced due to the impact of their mental illness:
(please tick all relevant options given episodic/changing nature of illness)
Complete substitute care Personal assistance (physical) Personal assistance prompting/supervision
Supported decision making Workplace/Home Modifications Assistive equipment
Other:
Frequency of ‘assistance’ required (or predicted) for this person to reasonably perform those daily activities that are Substantially and Permanently reduced due to the impact of their mental illness:
(please tick all relevant options given episodic/changing nature of illness)
Ongoing/regular assistance to manage daily activities and roles (permanent)
Periodic or occasional assistance (depending on stage of illness)
other
EVIDENCE THAT WE FEEL FURTHER DEMONSTRATES THE ‘DISABLING’ IMPACT OF THE PSYCHIATRIC CONDITION UPON THE DAILY FUNCTION OF THIS PERSON: eg. nature of further functional decline during periods of deterioration, -ve impact of medication on function, person is on DSP, assistance from Housing Department
Signature of person Completing Report: Date:
Name of person Completing Report: Relationship to applicant:
Organisation: Contact Details:
Disclaimer: This document has been developed by Health Directorate, Mental Health, Justice Health, Alcohol & Drug Services specifically for its own use. Use of this document and any reliance on the information contained therein by any third party is at his or her own risk and Health Directorate assumes no responsibility whatsoever.