A practical guide for allied health practitioners writing their first report for a new NDIS participant. Covers baseline establishment, assessment selection, and initial goal recommendations.
An initial assessment report is the first clinical document in a participant's NDIS file with your discipline. Everything that comes after, every progress report, every plan review recommendation, will be measured against the baseline you establish here. If the baseline is vague, future progress is impossible to demonstrate.
Initial assessments are typically requested when a participant first accesses your discipline under the NDIS, when they change providers, or after a significant gap in service. The report needs to establish where the participant is right now, identify what goals are appropriate, and recommend the supports needed to work toward those goals.
Unlike a progress report, you do not have previous session notes to draw from. You are working from the referral information, the participant's NDIS plan, your own assessment, and whatever history the participant or their family can provide. This makes tool selection and thorough documentation especially important.
Full participant name, NDIS number, date of birth, primary diagnosis, and relevant secondary diagnoses. Your full name, qualifications, AHPRA registration number, clinic name, and NDIS provider number. Date of assessment (or dates, if conducted across multiple sessions).
Who referred the participant (support coordinator, plan manager, GP, self-referral) and the specific reason for referral. Note the participant's current NDIS plan goals relevant to your discipline, quoted directly from the plan. If the participant has been assessed by your discipline before (by a previous provider or in a different context), note when and what was found. This helps the planner understand continuity of care.
Relevant medical, developmental, and social history gathered from the participant, their family, referral documentation, and any previous reports. Current living situation, support arrangements, and informal support network. Educational or employment participation. Previous therapy involvement: when, with whom, for how long, and what was achieved. Medications and their impact on function. Be thorough here but focused. Include information that affects your clinical reasoning and goal setting. Leave out information that does not.
List every standardised tool you administered: full name, edition, and date. Explain your rationale for selecting each tool. Not every assessment requires every tool. A CELF-5 is appropriate for a school-age child with language concerns but not for a 45-year-old with acquired brain injury. Document your informal assessment methods: clinical observation, structured or semi-structured interview, environmental assessment, review of video footage, review of school or workplace reports. State the assessment setting and who was present (participant, parent, carer, interpreter).
If you used an interpreter, name them and their language. Assessment validity can be affected by interpretation quality, and future clinicians need to know.
Present results from each standardised tool with scores and interpretation. This is the section that establishes the baseline. Be precise and comprehensive. For each tool, provide the date administered, composite scores with percentile ranks and confidence intervals, relevant subtest scores, and a plain-language interpretation of what the results mean for the participant's daily function. For informal assessments, describe what you observed in specific, measurable terms. 'Participant required two verbal prompts and one physical prompt to complete a three-step grooming routine' is a baseline measurement. 'Participant struggled with grooming' is not.
This baseline will be referenced in every future progress report. Invest the time to make it specific. Future-you will thank current-you.
A comprehensive description of the participant's current functional status across all domains relevant to your discipline. This goes beyond test scores to describe how the participant functions in their actual daily life. What can they do independently? What do they need help with? What type of help? How often? What are the safety concerns? What are the environmental factors affecting function? Connect your clinical findings to real-world activities.
Document what the participant is good at, what they enjoy, and what supports are already working. This is not filler. NDIS goals are meant to build on strengths and interests. A participant who loves cooking is more likely to engage with a goal about independent meal preparation. A participant with a strong family support network has a different starting point than one living alone. Protective factors (stable housing, engaged family, consistent routine) inform realistic goal setting.
Suggested NDIS goals for the current plan period, phrased in functional, participant-centred language. Each goal should be specific enough to measure progress against, linked to a functional need identified in your assessment, and achievable within the plan period. Write goals the participant would recognise as their own. 'I will develop the skills to shower independently with minimal verbal prompts' is participant-centred. 'Client will demonstrate improved ADL performance as measured by FIM scores' is clinician-centred.
Involve the participant (or their family) in goal setting where possible. Goals that reflect the participant's own priorities drive better engagement and better outcomes.
Specific support type, frequency, total hours per year, NDIS support category, and line item code. Any assistive technology or environmental modification recommendations with specifications and costs. Referrals to other disciplines, stating why and what questions the referral should address. If you are recommending a higher level of support than what is currently in the participant's plan, explain why your assessment findings justify the increase.
Signed declaration with full name, credentials, AHPRA registration number, and date. Sign and date every page.
Invest in the baseline
Every future progress report will compare back to what you document here. 'Participant required full physical assistance for all transfers' is a baseline. 'Participant had difficulty with transfers' is not. Be specific enough that a different practitioner reading your report in 12 months could measure the change.
Select tools deliberately
Use validated tools appropriate for the participant's age, cognitive level, and communication method. A standardised tool administered to someone it was not designed for produces invalid results. If no standardised tool is appropriate, document your informal assessment methodology thoroughly and explain why formal testing was not conducted.
Write goals the participant recognises
NDIS goals should reflect what the participant wants to achieve. 'I want to be able to catch the bus to TAFE by myself' is a participant goal. 'Participant will demonstrate improved community mobility skills' is a clinician goal. The first one drives engagement. The second one sits in a report nobody reads.
Include strengths
NDIA goal setting builds on strengths. Document what the participant can do, what they are interested in, and what supports are already working. A plan built only on deficits misses the person.
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