Therapist Online Form – West Byford Primary School

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Students Details

Students Name *

First

Last

Students Date of Birth *

DD/MM/YYYY

Parent/Carer Details

Parent/Carer Name *

First

Last

Provider Details

Name of Provider *

First

Last

Is your provider registered with the NDIS? *

Email address of the provider *

Company name (if applicable)

Inportant Information

Please provide the following information outlining the support the student needs access to, at school and during school hours. Note: Please complete another form if request includes more than one provider or a different type of support.

Details of the type of support to be provided. (What type of support will be provided? This may include reports, or information from the provider with details of the support to be provided and facilities required) *

Any relevant reports or information from the provider with details of the support can be uploaded here

File Upload *

Drag & Drop Files, Choose Files to Upload You can upload up to 100 files.

Unlimited number of files can be uploaded to this field. 128 MB limit.

How often will the support be provided, on what days of the week and at what time of day (e.g. Once a week on Friday from 11 am to 12 pm, or once every second Friday from 11am to 12pm). *

The dates the arrangement will need to be in place (e.g., from 1 January 2022 to 23 February 2022). School will not be open on school holidays. *

Please outline why the support needs to be provided at school, during school time. *

Department Requirements

Therapists on site are required to provide their NDIS Worker Screening OR the Department of Education’s NCCHC.

File Upload *

Drag & Drop Files, Choose Files to Upload You can upload up to 100 files.

Unlimited number of files can be uploaded to this field. 128 MB limit.

Upload an image of the provider’s current working with Children’s Check

File Upload *

Drag & Drop Files, Choose Files to Upload You can upload up to 100 files.

Unlimited number of files can be uploaded to this field. 128 MB limit.

Please attach proof of Public liability (minimum $20 million) and Professional indemnity (minimum $5 million)

form Inportant person

File Upload *

Drag & Drop Files, Choose Files to Upload You can upload up to 100 files.

Unlimited number of files can be uploaded to this field. 128 MB limit.

Name of person completing this form *

First

Last

Signature of person completing this form *

Clear Signature

Date this form was completed *