Full Name *

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

NDIA Managed Plan? *

Yes

No

Self-managed Plan? *

(invoices to send to clients email address otherwise stated

Yes

No

Please email the following to ot@pacehm.com.au

Additional relevant medical or therapy reports

NDIS Plan

Assessment/service to be completed/provided:

Functional Capacity Assessment

Assessment Paediatric Functional Capacity Assessment)

Complex Home Modifications

Assistive Technology

Supported Independent Living (SIL)

Specialist Disability Accommodation (SDA)

SIL/SDA

General therapy (no assessment)

Services Required

Occupational Therapy

Exercise Physiology

Dietetics