Referrer Details This referral is for* - required Myself Someone else Details of person completing form: Referral source:* - required [Choose One] Relative/friend Occupational therapist NDIS coordinator/ plan manager Other Name of referrer:* - required Contact number:* - required Email:* - required Participant details Title: [Choose One] Miss Ms Mrs Mst Mr Mx Family name:* - required Given name:* - required Home address:* - required Postcode:* - required Region:* - required Illawarra South Coast Eurobodalla Southern Highlands ACT Hunter Unsure what region the client's address falls in? Use our postcode locator search Tenure Owns home Owns home within retirement village (authority required) Rents private (authority required) Rents public Lives with family who own home (authority required) Date of birth:* - required Contact number:* - required Email:* - required Interpreter required:* - required Yes No Details of interpreter required: Provide details: Please provide details to help us arrange an interpreter i.e. client speaks Greek NDIS participant number:* - required NDIS plan start date:* - required NDIS plan end date:* - required NDIS plan management:* - required Self managed NDIS/ agency managed Plan nominee Plan management provider Plan nominee: Nominee name:* - required Nominee contact number:* - required Nominee contact email:* - required Plan management provider: Plan manager name:* - required Plan manager contact number:* - required Plan manager email:* - required NDIS plan Attach a copy of the participant's current NDIS plan and any related documents here: Select amount of documents to upload: 1 2 3 4 NDIS plan or related doc: Upload additional document Upload doc: Upload 2 additional documents Upload doc: Upload doc: Upload 3 additional documents Upload doc: Upload doc: Upload doc: NDIS Service request What service is required:* - required Occupational therapy (OT) assessment (NDIS support category 15_048_0218_1_3) - Therapeutic supports - individual assessment, therapy and/ or training (includes assistive technology) Builder consultation (NDIS support category 06_407_0111_2_2) - Home modification - consultation about home modification designs with a builder Quote - Home modification pricing Provide details of the service/ work requested: Alternative contact name: Alternative contact number: How did the participant find out about Scope Home Access: Home and safety access Adequate parking/ access:* - required Yes No Structural hazards:* - required Yes No Animals:* - required Yes No Other: 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. refreshGet Audio Code Type the code from the image Mandatory field(s) marked with *
