Fillable Practitioners Report This form need s to be (Southern Cross University)

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Practitioners Report This form need s to be (Southern Cross University)

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Country of origin: AUSTRALIA
File type: PDF

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Student Access & Inclusion
Practitioner’s Report
This form need
s to be completed by a Health Professional
Southern Cross University provides support and services for students with disability or medical conditions which may impact
on their participation. The following information will be used by Student Access & Inclusion to assist in providing the most
appropriate support for your patient/client. Please contact our Team on 02 6626 9514 or inclusion@scu.edu.au if you require
any further information.
CONSENT TO RELEASE/EXCHANGE INFORMATION
I, do do not give authority for Southern Cross University Student Access &
Inclusion staff to contact my health professional (details below), regarding documentation and the nature of my
disability/medical condition, and also for my health professional to contact Southern Cross University Student Access
& Inclusion Staff regarding documentation and the nature of my disability/medical condition.
Student sig
nature: Date:
Email: Phone:
PRACTITIONER’S DETAILS
Provider number:
Practic
e stamp:
Name:
Practice name:
Practitioner’s Signature:
Date:
GENERAL DETAILS
Diagnosis:
Expected duration of condition:
IMPACT OF DISABILITY OR MEDICAL CONDITION ON STUDY AT SOUTHERN CROSS UNIVERSITY
Please consider reading, writing, typing, cognitive functioning, sitting tolerance, energy levels, mobility and parking requirement etc.
EFFECT OF MEDICATION
Please consider concentration and memory, mobility and stamina, visual or other systems.
Student Number:
Student Name:
PERSONAL DETAILS
Who can complete this form?
Condition
Appropriate Medical Professional
Autism Spectrum Disorder
• Registered Psychologist
• Psychiatrist
Learning Disability (e.g. Dyslexia)
• Registered Psychologist
Neurological Condition (e.g. Acquired Brain Injury,
Cerebral Tumour)
• Neurologist
• Neuropsychologist
• Clinical Psychologist
• Psychiatrist
Hearing
• Registered Audiologist
Mental Health (e.g. Depression, Anxiety Disorder,
Eating Disorder)
• Registered Psychologist
• Psychiatrist
• GP Initially
Medical (e.g. Chronic Fatigue, Diabetes, Epilepsy)
• GP or Medical Specialist
Physical Impairment (e.g. Arthritis, Cerebral
Palsy)
• GP or Medical Specialist
Vision
• Ophthalmologist
• Specialist Service (e.g. Vision
Australia)
Temporary Condition or Injury
• GP
• Physiotherapist
• Occupational Therapist
• Medical Specialist
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Completed 24 August 2021

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