My Aged Care ID number Do you have a My Aged Care ID number?* - required Yes No If you have a My Aged Care ID number: My Details My Aged Care ID number:* - required Your My Aged Care ID number starts with 'AC' My Aged Care Referral Code (if you have one): Title:* - required Choose One Ms Mr Mrs Mst Mx Given name/s:* - required Family name:* - required Contact number:* - required Region:* - required Illawarra South Coast Eurobodalla Hunter Southern Highlands ACT Unsure what region the client's address falls in? Use our postcode locator search By clicking submit you are consenting to provide Scope Home Access with this information. All information is stored in line with our Privacy and Confidentiality Policy. To download a copy of this policy click here. If you do not have a My Aged Care ID number: Referrer Details Name of referrer:* - required Agency: Position: Contact number:* - required Email:* - required Address of agency/person paying:* - required Reason for Referral Reason for referral:* - required Home modifications Occupational therapy (OT) assessment Joint home visit with Scope builder Home maintenance Yard maintenance Are the modifications required for discharge from hospital:* - required Yes No Attach relevant documentation here: i.e. OT specifications Client Details Title: [Choose One] Miss Ms Mrs Mr Mst Mx Family name:* - required Given name(s):* - required Home address:* - required Postcode:* - required Region:* - required Illawarra South Coast Eurobodalla Hunter Southern Highlands ACT Unsure what region the client's address falls in? Use our postcode locator search Date of birth:* - required Contact number:* - required Email: Birthplace:* - required Language:* - required Interpreter required:* - required Yes No If an interpreter is required please provide details: Aboriginal or Torres Straight islander:* - required Yes No Alternative contact name: Alternative contact number: How did the client find out about Scope Home Access: Living Arrangements Client living arrangements:* - required Owns home Owns home within retirement village (authority required) Rents private (authority required) Rents public Lives with family who own home (authority required) Attach authority to commence work (if applicable): Client lives:* - required [Choose One] Alone With spouse/ partner With family Other If 'Other' selected please provide details: Package Approval Does client have a home care package:* - required Yes No If Client has a home care package please advise: Package level: Name of package provider: Package provider contact number: Home and Safety Access Adequate parking/ access:* - required Yes No Structural hazards:* - required Yes No Animals:* - required Yes No Other (provide details): Your name:* - required By clicking submit you are consenting to provide Scope Home Access with this information. All information is stored in line with our Privacy and Confidentiality Policy. To download a copy of this policy, click here. IT Support If you have issues submitting this form and would like assistance, please click here and enter any error details and/or images of the error. Mandatory field(s) marked with *