CHM
Client Details
Personal, contact, plan management and assessor details for this assessment. Required fields are marked with an asterisk.
NDIS Participant Details
Nominee / Guardian (if applicable)
NDIS Support Coordinator (if applicable)
Assessor Details
Plan Management Details
Select all that apply:
Upload previous OT, AT, or allied health reports for this participant. Clinical history, prior modification recommendations, functional trajectory, and clinical history will be extracted to inform the current report without overriding your intake data.
Clinical Assessment
Background, goals, frequency of use, agreement, and the functional findings table that drives the modification recommendations. Rough shorthand is fine — full prose is generated for the report.
2.1 Background
Diagnosis, prognosis, co-morbidities, formal and informal supports, and any other context relevant to the home modification need.
2.2 Participant's Goals
List the participant's NDIS goals that directly relate to the proposed modifications.
2.3.1 Frequency of Use of Proposed Modification
Tick all that apply. Frequency information is carried verbatim onto the report.
2.3.2 Participant / Nominee Agreement
Has the participant (and nominee, if applicable) agreed to the proposed modifications?
2.3.3 Functional Assessment Findings
For each row provide brief shorthand on the participant's current status and the expected outcome with the modification in place. Leave a row blank if not applicable.
Property & Social Context
Home ownership status, structural details, and the social situation that the modifications must support. Property ownership and previous-modification fields are carried verbatim onto the report.
3.1.1 Home Ownership Status
Tick all that apply.
3.1.2 Previous NDIA-funded Modifications
Has the participant previously received NDIA funding for home modifications at this property?
3.1.3 Owner Authorisation
Has the property owner provided written authorisation for the modifications? (Required when participant is not the sole owner.)
3.2 Property Structure
OT shorthand notes on construction type, era, foundation, and any structural specifics relevant to the proposed modifications.
3.3 Property Description
OT shorthand notes on layout, size, terrain, and access.
3.4 Special Conditions
Heritage listing, body-corporate restrictions, easements, or other special conditions affecting the modifications.
4.1 Social Circumstances
Living arrangements, household composition, family supports, and the social context that informs the modification need.
4.2 Hospital / Inpatient Status
Tick the box if the participant is not currently an inpatient — this section will be skipped on the report.
4.3 Proposed Living Arrangements
Long-term household and social arrangements, expected duration of residence in the modified home, and any known future changes.
Modification Recommendations
Per-room current situation, recommendations, and clinical evidence linking modifications to the participant's deficits. Tick Not Applicable for any room that does not require modification — the report will leave those sections blank. Priority numbers are entered verbatim and never AI-generated.
5.1 External Modifications
5.2 / 5.3 Internal Modifications
5.4 Heating & Cooling
Tick the box only if the participant has a medically diagnosed thermoregulation impairment (e.g. SCI, MS) requiring thermal modifications. The section is skipped on the report otherwise.
5.5 Staged Implementation Process
Are the modifications recommended for staged implementation (e.g. stage 1 enables hospital discharge, stage 2 transitions to long-term residence)?
5.6 Exception to Disability Standards
If any recommended modification departs from AS 1428.1 or other applicable standards, document the exception and clinical justification here. Leave blank if all recommendations comply.
Quotes, Declaration & Generate
Builder quotes summary, OT declarations, builder review, and consent. Once everything is in place, generate the final CHM Assessment Report.
6 Quotes
Brief OT-shorthand summary of attached builder quotes, scope-of-works documents, and project management arrangements.
7 Declarations
Confirm the assessor's declarations before generating the report.
7 Builder Review (optional)
If a registered builder has been consulted on the modifications, capture their details here. All fields are verbatim — leave blank if no builder has yet been consulted.
8 Participant Consent
Has the participant (or their nominee) consented to the collection and sharing of information in this report?
