30/01/2020
To Whom It May Concern,
Re: Jane D
DOB: 20/06/1992
NDIS Reference Number: XXXXXXXX
OT Initial Assessment and Recommendations
This letter is to provide you with a summary of the Occupational Therapy assessment and clinical intervention that is
currently being recommended for Jane D.
Background Information:
Jane Dis a 27-year-old woman od Sudanese descent. She has a diagnosis of Autism obesity and has epileptic seizures.
She currently lives with her family consisting of mother and 2 sisters. Jane D enjoys reading and writing, assisting with
hanging the laundry and loves gardening. Jane D requires assistance to continue living at home independently.
Current Functional Status:
Please find below a summary of Jane D’s current level of function:
Activity
Home Environment
Status/ Function
Jane D lives home with her mother and 2 sisters. Jane D has her own bedroom
that’s on the ground floor of the house. Her bedroom is close to the bathroom
and kitchen. The home environment is clean and does not have any clutter and
cords are safely tucked away from common areas.
Functional Mobility
(Indoor/Outdoor)
Jane D mobilizes independently without special equipment/ gait aids. Jane D
enjoys going for walks outdoors with family and carer. She can tolerate walking
for a long distance however, once tired, Jane D will stop walking.
Transfers
Jane D can independently complete her transfers from bed, chair and toilet.
Jane D however has seizures and requires supervision throughout the day to
ensure she is safe and prevent risks of harm during an epileptic episode.
Showering
Jane D can shower independently however, due to having seizures, she requires
supervision while showering to ensure she is safe in the bathroom. She also
requires a lot of prompting to remember to shower or becomes forgetful of her
hygiene. Jane D requires assistance with prompting to shower.
Dressing/ grooming
Jane D has difficulties with putting on her shoes. She becomes confused with
which shoe is to be worn on which foot. She tends to put on the shoes on the
wrong foot. Jane D has difficulties with buttoning up her buttons. She put on
the buttons wrong and at times is unable to manipulate the buttons and gives
up.
Jane D has difficulties remembering to brush her teeth during the day. If she is
not reminded to do so, she does not brush her teeth. This could lead to oral
hygiene infections and difficulties. She requires assistance to complete task of
buttoning up her buttons, putting on her shoes correctly and prompting to
remember to brush her teeth.
Meal preparation
It is unsafe for Jane D to cook herself hot foods or use the stove due to seizures.
Jane D has had seizures while handling hot food which resulted in burns. Jane D
will require assistance with preparing hot meals.
Cleaning
Jane D assists her family with cleaning. She enjoys cleaning the dining area and
doing the dishes. Jane D has difficulties with cleaning tasks such as, vacuuming,
cleaning the bathroom and toilet. She requires assistance with completing the
task
Laundry
Jane D enjoys hanging clothes on the line. She can complete the task of hanging
clothes on the line independently. Jane D has difficulties with selecting clothes
for the wash cycle and has difficulties with starting the washing machine. Jane D
will require assistance with selecting light and dark coloured clothes for the
wash cycle.
Home maintenance
Jane D finds it difficult to maintain the home alone. Her mother and sisters go to
work and without a carer, she would be left alone at home. Jane D requires a lot
of supervision within home environment due to having seizures and will require
assistance with keeping the home clean and safe.
Leisure
Jane D enjoys gardening, going outdoors for walks and going to the shopping
malls.
Ongoing Clinical Intervention Recommended:
The following is a breakdown of the clinical intervention now being recommended. Please note that the hours outlined
may also include necessary non-direct contact time such as report writing, liaising with treating team and equipment
suppliers, and the development of specific resources.
OT Initial Assessment and Recommendations
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There may be times, for unanticipated reasons, where a task may take longer than has been estimated. If this is to
occur your treating therapist will discuss this with you. If a task takes less time than has been estimated, you will only
be invoiced for the time it has taken.
Please note that services will be billed at $193.00 per hour for home-based intervention.
The following recommendations have been made for Occupational Therapy (OT) specific hours. The treatment plan
outlined cannot be completed by an allied health assistant as they require specialist skills held by an OT. In the event
where an alternate service can provide the intervention, this has been highlighted.
OT Goal 1:
NDIS goal:
Clinical justification/
risks to participant if
not funded:
To engage in social activities/events
Jane D has autism and experiences epileptic seizures. She is unable to engage with the
wider community independently. Without a carer, Jane D spends her time alone at home
as her family must go to work. This leads to Jane D being isolated with the wider
community, leading to feelings of loneliness and depression.
Due to her condition of autism and due to social isolation, Jane D has difficulties engaging
with unfamiliar individuals. By encouraging her to socialize more she will gain more social
skills and gain new friends and social networks. This benefit her overall wellbeing
positively.
Actions/ intervention
required:
Occupational Therapist to assist with:

Engage Jane D in social activity groups

Engage Jane D in public festivals with carer and family members.

Observe Jane D in social activities and adapt interventions to her current
engagement with other individuals attending.
Hours required:
Outcome measure:
NDIS budget:
OT Goal 2:
NDIS goal:
Clinical justification/
risks to participant if
not funded:
10 hours
Goal Attainment Scale
Capacity Building
To independently complete ADLs independently
Jane D has difficulties with completing ADLs relating to her hygiene independently. She
has difficulties with brushing her teeth, doing up buttons, putting on her shoe on the right
foot or brushing her hair. Jane D requires assistance to complete her ADLs which therefore
diminishes her independence and her self-confidence in her abilities.
Actions/ intervention
required:
Occupational therapist to assist with:
 Facilitate Occupational Therapy based interventions to assist with ADLs task
training, with a focus on dressing and grooming to promote her independence.
OT Initial Assessment and Recommendations
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
Carrying out functional assessments and observation of Client’s safety and
current participation levels within all personal and domestic tasks; with
consideration to current physical functioning.

Continued provision of carer supports for both attendant care and community
access
Hours required:
Outcome measure:
NDIS budget:
OT Goal 3:
NDIS goal:
Clinical justification/
risks to participant if
not funded:
Occupational Therapist recommends periodic (every 3-6 months) reviews of Client’s
improvement in completing morning tasks with her children and adapt task according to
result of review.
20 hours
Goal Attainment Scale
Capacity Building
Learn skills to regulate my emotions
When Jane D becomes agitated and upset, she becomes aggressive and physically attacks
those around her. She previously attended day school however, she was expelled due to
her physical aggression towards other individuals at the day school. Without the skills to
regulate her emotions Aurella, will continue to be aggressive towards individuals in the
wider community. This will lead to Jane D having to be separated from others for safety
concerns, and she will therefore continue to remain isolated and lonely.
Actions/ intervention
required:
Occupational therapist to assist with:
 Facilitate Occupational Therapy based interventions to assist with emotion
regulation

Carrying out functional assessments and observation of Client’s progress with
gaining skills to regulate emotions.
Hours required:
Outcome measure:
NDIS budget:
20 hours
Capacity Building
Areas of Unmet Need:
The following areas of unmet need have identified. Please see below a detailed list of the additional formal supports
being recommended for inclusion in Jane’s next plan.
Unmet need 1:
Recommendation:
Social Worker.
Clinical justification/ Jane D may require support from a Social worker to assist her with any issues she is facing
risks to participant if
in her daily living. She is very vulnerable due to her social isolation and is in need to have
not funded:
OT Initial Assessment and Recommendations
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many supports. A social worker will be able to assist Jane D receive all the support she
needs professionally and socially.
Hours required:
NDIS budget:
Unmet need 2:
Recommendation:
Clinical justification/
risks to participant if
not funded:
Hours required:
NDIS budget:
As per treating clinician’s recommendations
Speech Therapist.
Jane D has slurred speech when speaking. She requires a speech therapist to conduct
speech therapy assessments and intervention strategies to improve her speech.
As per treating clinician’s recommendations
Please feel free to contact your treating clinician to discuss this further.
Clinician: Clare Jones
Contact Number: 042637495
Email: Claire.jones@otblock.com.au
OT Initial Assessment and Recommendations
Signature:
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