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 If other: Please specify: 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 please refer to the end of this page. 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 Additional documents Select amount of additional documents to upload (if required): 1 2 3 Upload additional document: Upload doc: Upload 2 additional documents: Upload doc: Upload doc: Upload 3 additional documents: Upload doc: Upload doc: Upload doc: Home and Safety Access Adequate parking/ access:* - required Yes No Structural hazards:* - required Yes No Animals:* - required Yes No Other (provide details): 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. 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. Mandatory field(s) marked with * Authority to Commence Work To download a copy of our Authority to Commence Work document, click here.