FUNCTIONAL CAPACITY ASSESSMENT

Person making referral and contact information

Participant Name

Phone Number

Date of Birth (YYYY-MM-DD)

Home Address

NDIS Participant Number

Participant representative

NDIS participant requires support for their: *

Diagnosis and background information

Why do you require a FCA? *

NDIS Plan Review – The participant's plan is coming to an end, and they need a FCA as supporting evidence for their NDIS review. Due to a change of circumstance – The participant's functional ability has changed, and they need a FCA to show the increased need for NDIS support, services, and the level of funding required. Due to a change of circumstance – Insufficient funding within current NDIS plan – Requires a FCA as evidence to demonstrate an increased level of support and funding. I have been recommended to have a Functional Capacity Assessment

NDIS Plan goals

Service Location

NDIS Plan Start Date (YYYY-MM-DD)

NDIS Plan End Date (YYYY-MM-DD)

Coordinator of Supports (COS) details

NDIS Plan Management*

NDIA-Managed Self-Managed Plan Managed

Plan Managed details

At Raymond Terrace Therapy, we pride ourselves on providing the highest quality level of service. The scheduled time required to complete a Functional Capacity Assessment is 15-20 hours, this includes direct and indirect service provision.*

I confirm that I have up to 20 hours Capacity Building (CB) funding for my FCA. I confirm that I have Core funding which I can access as my CB funding has been exhausted. I do not have any current funding for this service, however, wish to place a referral for when funding is available.

Thank you for your response. ✨