Referrer Details

This referral is for:* - required
If someone else:

Client Details

Unsure what region the client's address falls in? Use our postcode locator search.


Tenure:* - required
If other:
Interpreter required:* - required
If interpreter required:
Please provide details to help us arrange an interpreter i.e. client speaks Greek
Does the client have a carer:* - required
If client has carer:
Co-resident carer:

Package Approval 

Does the client have a home care package:* - required
If client has a home care package:
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
If occupational therapy assessment:
What documentation is required? Select all that apply:* - required
Has the client had any falls in the last 12 months:* - required
Has the client had any recent hospitalisations:* - required
If home modifications:
i.e. OT specifications
If yard maintenance:
i.e. OT specifications
If home maintenance:
i.e. OT specifications
Additional documents
Upload additional document:
Upload 2 additional documents:
Upload 3 additional documents:

Home and Safety Access

Adequate parking/ access:* - required
Structural hazards:* - required
Animals:* - required
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.