Trial Request Form

Therapist Details

Therapist's Name

Organisation

Days therapist works

Phone Number

Mobile Number

Email Address

Address

Qualifications (ie OT/PT)

Equipment Details

What equipment do you require?

Source of funding?

What equipment does the child currently have?

What is the goal of the trial for the family and therapist?

Address of Trial to take place?

Describe access to place of trial (eg: stairs, gate, etc)

Client Information

Name

Address

Gender Male Female

D.O.B

Carer's Name

Email Address

Home Phone

Mobile Number

Social Situation (Foster care arrangements, respite, difficult prognosis)

Does the child or any persons attending the trial have an infectious disease or illness? Yes (Please provide details) No

If yes, please provide details

NDIS Details

Does the child have an NDIS plan? Yes No

If no NDIS plan, please choose: Client has No NDIS plan as yet (as they are still waiting for approval thru NDIS) and then pls ask client to provide any other details (eg have they had their Pre Planning meeting yet?) Other funding source applies to this client (eg BetterStart, MASS, HCWA, Private/ personal funding, charity funding eg Variety etc ) School or other organisation trial/ funding (please specify details) Other (please specify details)

Please specify details

If so please provide NDIS Participants Plan number and plan dates

Please state whether the client is Agency Managed, Plan Managed or Self managed. Agency Managed Plan Managed Self Managed

Is the Plan under Review and if so, what the Review dates will be?

Which Support Category has money been allocated to for purchase of AT?

Please could you ask the participant to provide the AT section of their plan (this is generally in a box on about page 5 of their plan). We do not require all their confidential plan details, but just a screen shot or similar of their actual AT section. PLEASE SEND THESE DETAILS IN A SEPARATE EMAIL

We cannot proceed to booking a trial without this information, so pls provide this ASAP and we will be glad to book a date for the trial to occur.

Medical Details

Diagnosis / Disability

Dislocated hips Yes No

Cardiovascular difficulty Yes No

Breathing difficulity Yes No

Swallowing difficulty Yes No

Asymmetrical posture Yes No

Pain Yes No

Location/Severity

Pressure areas Yes No

Location/Severity

Muscle Tone (Describe)

Postural requirements of child? (eg; Laterals, head support)

Actual Body Measurements

A mm Height from seat surface to top of head.

B mm Height from seat surface to top of shoulder.

C mm Seat depth (length from behind knee to backrest)

D mm Height from heel to back of knee.

E mm Chest width.

F mm Hip width (from greater trochanter to great trochanter).

G mm Under arm to foot (for standing)

H mm Inner seam measurement (groin to heel)

I mm Elbow to floor measurement.

Weight kg

Height cm

By clicking the “Request Trial” button, you agree to the following Terms & Conditions:

• All requests for demonstration equipment are to be in writing, on the attached form.
• All loan equipment from Special Needs Solutions remains the property of Special Needs Solutions. Please inspect the equipment upon arrival and make sure that it is in good condition. Please notify SNS on 07-5527 9794 if the item is damaged or incomplete.
• SNS will send equipment via courier/post to the therapist or client. Return freight costs are to be borne by the therapist loaning/trialling the equipment. Therapists are expected to use a reputable freight carrier, to ensure that the equipment can be tracked and is carried safely. They are also expected to pack the goods safely and securely, using adequate padding and suitable boxes. Therapist will be responsible for replacing any goods which are damaged in transit through inadequate packaging.
• Therapists will take full responsibility for the care of the items and are financially and legally liable for any damage to equipment or persons due to misuse occurring during this trial period.
• All SNS Trial items are to be used under the supervision of the borrowing therapists only and are not to be left with the client without prior written consent of SNS (see Trial Request Form). It is for demonstration purposes only and is to be used for ‘dry runs’ only (ie shower chairs and toilet chairs are not to be used).
• Therapist/client must read the instructions carefully and use the equipment appropriately, for demonstration or short trial only and must not expose the equipment to moisture, food or other adverse conditions. Where equipment is used for self care purposes, the equipment is to be used for “dry runs” only. Where the demonstration equipment has options and accessories fitted to it and the therapist removes these for trial, they must be refitted to the equipment prior to it being returned. The equipment should be in the same configuration as it was when it was sent. No stickers/tags are to be affixed to the products.
• SNS does not guarantee that equipment will be available for loan or the timing of that loan. Where equipment is not available on date requested by therapist SNS will arrange a more suitable date and time with the therapist.
• All loan products are to be returned in the same condition on the due date specified. All extensions are to be requested in writing to SNS.
• SNS are happy to arrange to meet in person with customers or therapists. Please contact us to arrange this if required. SNS are also available if you need assistance or further information regarding equipment trial or these terms and conditions.
• Customer feedback, whether good or bad is greatly appreciated so please feel free to contact us via email.
• SNS may, at their discretion, choose to leave a piece of equipment with an organisation/client on a long term loan. In this situation, the therapist/organisation/client is responsible for ensuring that the equipment is well maintained and returned to SNS upon request.
• If the equipment is lost or damaged, the organisation/therapist/client will be responsible for paying for the full value of the equipment.