Any supporting documentation you wish to provide may assist us to make a faster assessment of this application. 1. Unable to 2. 3. Does not 4. Does not do or always Sometimes need help but need help and needs help/ needs help/ uses aids does not use supervision supervision /equipment aids/ equipment ☐ ☐ ☐ ☐ a) Self-care: washing Please describe help/equipment needed: dressing eating toileting ☐ ☐ ☐ ☐ b) Mobility moving around home Please describe help/equipment needed: getting in/out of a bed or a chair transport private – and/or public Section 7 Help and supervision – 1. Unable to 2. 3. Does not 4. Does not do or always Sometimes need help but need help needs help/ needs help/ uses aids and does not supervision supervision /equipment use aids/ equipment
Any supporting documentation you wish to provide may assist us to make a faster assessment of this application. 1. Unable to do or always needs help/ supervision 2. Sometimes needs help/ supervision 3. Does not need help but uses aids /equipment 4. Does not need help and does not use aids/ equipment a) Self-care: washing dressing eating toileting ☐ ☐ ☐ ☐ Please describe help/equipment needed: b) Mobility moving around home getting in/out of a bed or a chair transport – private and/or public ☐ ☐ ☐ ☐ Please describe help/equipment needed: Section 7 – Help and supervision 1. Unable to do or always needs help/ supervision 2. Sometimes needs help/ supervision 3. Does not need help but uses aids /equipment 4. Does not need help and does not use aids/ equipment
WA-Disability-Professional-Services-school-age-referral-form-2014.docx