Request A Driving Assessment Name * First Name Last Name Preferred Name Phone * (###) ### #### Email * Date of Birth * MM DD YYYY Gender * Male Female Non-Binary Other GP Name and Clinic * Diagnosis * Referrer Reason for Referral Client Drivers Licence Number * Drivers Licence Expiry Date MM DD YYYY Current Licence Type * Manual Automatic I do not have a current licence Heavy Vehicle Motorbike Address on Drivers Licence Address 1 Address 2 City State/Province Zip/Postal Code Country Next of Kin * First Name Last Name Next of Kin Phone * (###) ### #### Are you a current or returning client of Mind Life Clinic? * Yes No Method of funding * Fully self-funded National Disability Insurance Scheme (NDIS) What makes driving difficult for you? * Please provide any additional information relevant to your OT Driving Assessment Payment * Mind Life Clinic requires payment in full prior to the Clinical Assessment. An invoice will be forwarded to your email address once an appointment is booked. I agree Cancellation Policy * Mind Life Clinic has a very strict cancellation policy. Any client who “no-shows” or cancels within 24 hours of their appointment will be charged a $90 fee. No further appointments will be permitted until the cancellation fee has been paid. I agree Additional Fees * The use of a disability-trained Driving Instructor and Test Vehicle is a separate business to Mind Life Clinic and a requirement of the OT Driving Assessment. This attracts an additional fee of approximately $320. I agree Thank you for submitting an appointment request. We will aim to contact you within 48 hours.
