Mobility for Life
Referral and outcome summary

Completed by EMS Assessor

Assessment date: Date

I confirm that I have informed the individual that their personal information is being collected by me and will be provided to Enable New Zealand for the purposes of referral, assessment, funding decisions, equipment provision, and related oversight under the Mobility for Life project.

Appointment details
Telehealth appointment required to determine power wheelchair and seating solution	Choose an item.
Clinic appointment required to set up purchased power wheelchair and seating	Choose an item.
Venue address for clinic appointment	Address for clinic appointment

Person’s details
Last name	Last name	First name(s)	First name
NHI Number	NHI	Date of birth	Date of birth
Gender	Gender	Ethnicity	Ethnicity
Email address	Email address	Phone number	Phone number

EMS Assessor’s details
Assessor name	Name	AEA number	AEA number
Phone Number	Phone number	Email Address	Email address
Accreditation	Choose an accreditation credential
Preferred method of contact	Choose a method of contact
Preferred time/day for contact	Enter time(s) and day(s).

Eligibility
Primary diagnosis	Select a primary diagnosis
Coexisting condition or other	Click or tap here to enter text.
Resides	Choose an item or type your own.

Explanation of Situation

Person’s goals

Please list the five goals identified in the WATCh or WATCh-Ad.

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Background information

Describe the person’s living situation, whānau, formal support, roles, any physical and/or emotional factors affecting them or their caregivers and predicted transitions.

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Current functional ability and physical findings

Please include details of the persons current wheelchair and seating equipment, strengths, and functional limitations/disabilities.

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Clinical reasoning for your proposed solution

Please include rationale relating to the person’s physical needs. Explain how the proposed solution will improve independence, participation, health, and wellbeing, now and over the next two years, and any potential risks of not providing this solution.

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Proposed power wheelchair and seating solution

Please list the proposed solution. If a panel supplier is unable to provide a suitable seating solution, please outline the clinical and functional reasons why, and identify the panel seating options that have been considered and excluded.

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Completed by Mobility for Life Clinical Lead

Details of telehealth appointment to problem-solve solution
Date	Date
Present	People present
Consultation notes (new discussion points etc)	Click or tap here to enter text.
Outcome and final solution	Click or tap here to enter text.
Plan	¨ Solution meets Mobility for Life Research criteria and will be funded ¨ Clinical Lead to request power wheelchair quote and purchase of all equipment supported EMS Assessor to organise for all purchased equipment to be set up with the person and relevant suppliers outside of clinic ¨ Clinic appointment required for set up of all purchased equipment ¨ Solution does not meet Mobility for Life Research criteria, consider alternative solutions ¨ Other: Enter text All solutions are supported and funded under the Mobility for Life Research Project for Power Wheelchairs. Any future solutions will need to be considered in accordance with the Disability Support Services (Ministry of Social Development) funding criteria and the processes in place at that time.
Date completed	Date
Name	Name	Designation	Designation

Details of appointment to set up power wheelchair and seating
Date	Date
Present	People present
Consultation notes	Click or tap here to enter text.
Date completed	Date
Name	Name	Designation	Designation