Referrer Details This referral is for:* - required Myself Someone else If someone else: Name of referrer:* - required Agency: Position: Contact number:* - required Email: Address of agency/ person paying:* - required Client Details Title: [Choose One] Miss Ms Mrs Mr Mst Mx Family name:* - required Given name(s):* - required Date of birth: Contact number:* - required Email:* - required Home address:* - required Postcode:* - required Region:* - required Illawarra South Coast Eurobodalla Southern Highlands Hunter ACT Unsure what region the client's address falls in? Use our postcode locator search. Tenure Tenure:* - required Owns home Owns home within retirement village (authority required) Rents private (authority required) Rents public Lives with family who own home (authority required) Client living arrangements:* - required [Choose One] Alone With spouse/ partner With family Other Interpreter required:* - required Yes No If interpreter required: Provide details:* - required Please provide details to help us arrange an interpreter i.e. client speaks Greek How did the client find out about Scope Home Access: Does the client have a carer:* - required Yes No If client has carer: Carer contact name:* - required Carer contact number:* - required Relationship to client: Co-resident carer: Yes No Package Approval Does the client have a home care package:* - required Yes No If client has a home care package: Package level:* - required Name of package provider:* - required Package provider contact number:* - required Attach authority to commence work (if applicable): To download a copy of our authority to commence work document, click here. If other: Please specify: Reason for Referral Reason for referral:* - required Occupational Therapy (OT) Assessment Home Modifications Home Maintenance Yard Maintenance If occupational therapy assessment: What documentation is required? Select all that apply:* - required Works request OT report Provide details of the clients medical history/ impairment issues: Has the client had any falls in the last 12 months:* - required Yes No If yes, provide details of the clients falls history:* - required Has the client had any recent hospitalisations:* - required Yes No If yes, provide details of clients recent hospitalisations: If home modifications: Provide details of the service required:* - required Attach relevant documentation here: i.e. OT specifications If yard maintenance: Provide details of the service required:* - required Attach relevant documentation here: i.e. OT specifications If home maintenance: Provide details of the service required:* - required Attach relevant documentation here: i.e. OT specifications Home and Safety Access Adequate parking/ access:* - required Yes No Structural hazards:* - required Yes No Animals:* - required Yes No Other (provide details): 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 *