Sense Therapies Report & Letter of Support Request

Therapy Type *

Occupational Therapy - $226.31p/hrSpeech Therapy - $226.31p/hrArt Therapy - $226.31p/hrPsychology - $232.99p/hrTerm Groups Only Participant - $226.31p/hr

Name of Participant's Current Sense Therapies Therapist *

Date Report/Letter of Support Required *

Type of Document Required - NOTE : Reports are completed during School Holiday Breaks *

NDIS Plan Review Report - cost 3hrs (min)NDIS Initial Funding Application Letter/Report - cost 3hrs (min) Letter of Support - cost 3hrs (min)Functional Assessment & Report - cost 8-10hrs (min)Term Groups Only Participants : Letters of Support - cost 1-2hrs (min)

Participant First Name *

Participant Surname *

Participant D.O.B *

Pronouns

Full Name of Person Requesting Document Preparation *

Email Address *

Mobile Number *

Relationship to Participant *

Who is the intended audience eg : school, NDIS, paediatrician etc *

What are the specific points you wish the Report/Letter of Support to highlight *

NON-FUNDED Participant - Individual's email for Invoice Payment (if applicable) *

NDIS Plan Manager's email (if applicable) *

NDIS Number - ENSURE DETAILS CORRECT & COMPLETE (if applicable) *

Current NDIS Plan Start Date (if applicable) *

Current NDIS Plan Finish (if applicable) *

Payments *

NDIS Plan ManagedNDIS Self Managed Plan Private Health Insurance Self Funded/Out of Pocket

I understand full payment of all invoice/s related to any formal document preparation is required prior to the release of the document. *

DOCUMENT PREPARATION NOTICE PERIOD : *

Standard Report &/or Letters of Support - min. four (4) weeks notice, commencing from the date all necessary supporting documents provided to OT by Participant.Functional Capacity Assessments & Report - eight (8) to 10 weeks in total.for entire process - NOTE : Reports are completed during School Holiday breaks.

SUPPORTING DOCUMENTATION *

I have attached relevant documentation I will be submitting relevant documentation at a later dateThere are no further supporting documents to be submitted

Please attach any relevant documentation or reports.

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Primary Carer/Guardian Signature *

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Date of Submission *