Phone: My disability is: If it’s the first time you have worked with us, and you have a diagnosis of Intellectual Disability or Autism Spectrum Disorder, please attach relevant specialist reports. For all other diagnosis you can ask your doctor or specialist to fill out a your ‘Confirming disability’ form. This is available on our website: I also live with these medical/mental health/accident-related conditions: 4. Reasons for application How urgently do you feel that you need support in your current situation? Non urgent Semi urgent Urgent (application progressed within (application progressed (application progressed one week) within 2 days) within 1 day) Describe the reasons for your application. What do you need support with because of your disability? Describe any safety, hazards or sensitive issues that AccessAbility staff need to know about. What other people or organisations are you working with? This includes places you currently receive support from. Specialist: ACC: Social worker: Paediatrician: Therapist: Agencies: Psychologist:
Phone: My disability is: If it’s the first time you have worked with us, and you have a diagnosis of Intellectual Disability or Autism Spectrum Disorder, please attach relevant specialist reports. For all other diagnosis you can ask your doctor or specialist to fill out a ‘Confirming your disability’ form. This is available on our website: I also live with these medical/mental health/accident-related conditions: 4. Reasons for application How urgently do you feel that you need support in your current situation? Non urgent (application progressed within one week) Semi urgent (application progressed within 2 days) Urgent (application progressed within 1 day) Describe the reasons for your application. What do you need support with because of your disability? Describe any safety, hazards or sensitive issues that AccessAbility staff need to know about. What other people or organisations are you working with? This includes places you currently receive support from. Specialist: Social worker: Therapist: Psychologist: ACC: Paediatrician: Agencies:
Application-Needs-Assessment-2016.docx