133 Adelaide Street Maryborough 07/4123 2234

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Home Care Package Major Modifications Referral Form

For Home Care Package Major Modifications (over $3,300.00)

Form Reference Number 4

Title *

First Name *

Surname *

Preferred Name

Country of Birth

Language

Date of birth *

Street Address *

City

ZIP / Postal Code

Postal Address (if different from above)

City

ZIP / Postal Code

Phone Number *

Mobile

Email Address

Additional Contact Person

Relationship to Client

Phone

Mobile

Consent to act on behalf of recipient

Residency Type *

Owner / Landlord / Agency Name (if applicable)

Owner / Landlord / Agency Postal Address

Suburb and Postcode

Phone

Mobile

E-Mail

Home Care Package Level *

HCP Provider *

HCP Contact Person *

HCP Postal Address *

City

ZIP / Postal Code

Phone *

Mobile

Email Address *

Occupational Therapists Name *

Occupational Therapist Organisation

Phone *

Mobile

Email Address *

Type of Modification *ShowerToiletBathroom AlterationRampKitchenOther* Please note we no longer provide quotes for Stairlift, Platformlift or Waterlift Modifications for Home Care Packages, please contact Lift Installers direct for quotes.

Other, please elaborate *

Home Care Package Budget Allowance for Modification(this is requested, so the budget can be taken into consideration in the design)

Fee for Service

1 Home Assessment by Home Assist Community Services builder with Occupational Therapist.

1 Floor plan (this allows for one revision of of floor plan only).

Total = $125.00 Inc GST

Quote

The quote for the requested modifiation will then be provided to the Home Care Package Provider for their consideration.

Please note a $55.00 quote fee is payable if quote is not accepted.

Cancellation

Home Assist Community Services will charge a $55.00 fee if a referral is cancelled 24 hours after submission.

All work requested has been discussed *

All work requested has been discussed with and has the consent of the client and their Home Care Package Provider. Client and Home Care Package Provider are aware and accept the fees outlined above.

Name of person submitting referral *

Phone Number *

Would the Occupational Therapist like to attend the builders assessment?

Preferred Appointment for assessment visit with builder

Preferred Time

Hours

Minutes

File Upload (if required)

No file chosen

For Uploads over 8MB, please use one of the free of charge file transfer services for example https://wetransfer.com/

Please send a copy of this form submission to

Submission Date *

Please do not fill in this field.

Home Assist Community Services

- Work For Us -

Non-Profit Organisation Established in 1999 - QBCC Builders Registration: 1109355 ABN: 82493405845
Home Assist Community Services 133 Adelaide Street Maryborough QLD4650 - Phone 07/4123 2234 Monday to Friday 9am until 3pm (message bank after hours)

Incident Management

133 Adelaide Street Maryborough 07/4123 2234

07 4123 2234

Login

Home Care Package Major Modifications Referral Form

Call Us Now 07 4123 2234

Apply For Support

I need Help finding a form

Home Assist Community Services

- Work For Us -

Non-Profit Organisation Established in 1999 - QBCC Builders Registration: 1109355 ABN: 82493405845
Home Assist Community Services 133 Adelaide Street Maryborough QLD4650 - Phone 07/4123 2234 Monday to Friday 9am until 3pm (message bank after hours)

07 4123 2234

Login

Home Care Package Major Modifications Referral Form

Call Us Now 07 4123 2234

Apply For Support

I need Help finding a form

Home Assist Community Services

- Work For Us -

Non-Profit Organisation Established in 1999 - QBCC Builders Registration: 1109355 ABN: 82493405845 Home Assist Community Services 133 Adelaide Street Maryborough QLD4650 - Phone 07/4123 2234 Monday to Friday 9am until 3pm (message bank after hours)

Non-Profit Organisation Established in 1999 - QBCC Builders Registration: 1109355 ABN: 82493405845
Home Assist Community Services 133 Adelaide Street Maryborough QLD4650 - Phone 07/4123 2234 Monday to Friday 9am until 3pm (message bank after hours)