HCP and STRC Brokerage To be completed by Home Care Package providers for requestsTo be completed by Occupational Therapists for minor modification requests Form Reference 00Date of Referral *Type of Referral *Please chooseMinor ModificationsMaintenanceDomestic AssistanceOccupational Therapist Name *Occupational Therapist Business *Occupational Therapist Email *Occupational Therapist Phone Number *Does the Person have a Home Care Package or STRC? *Please chooseHCP Level 1HCP Level 2HCP Level 3HCP Level 4STRCSDASTRC start Date *STRC End Date *Title *Please chooseMrMrsMissMsOtherFirst Name *Surname *Preferred NameDate of birth *Country of Birth *Language spoken *Street Address *City *Postal Code *Phone Number *MobileAdditional Contact PersonPhoneRelationship to ClientConsent to act on behalf of consumerPlease chooseYesNoResidency Type *Please chooseFamily OwnedConsumer OwnedPrivate RentalPublic RentalIndependent Living UnitOwner / Landlord / Agency Name (if applicable) *Owner / Landlord / Agency Postal AddressSuburb and PostcodePhone *MobileEmailDwelling Details *Please chooseHigh SetLow SetOtherHCP/STRC Provider *HCP/STRC Contact Person *Address *Phone Number *Email Address *Email Quotes to (if different)Email Tax invoices to (if different)Work Requested/Instructions *File Upload *Drag and Drop (or) Choose FilesFor Uploads over 8MB, please use one of the free of charge file transfer services for example https://wetransfer.com/File UploadDrag and Drop (or) Choose FilesFor Uploads over 8MB, please use one of the free of charge file transfer services for example https://wetransfer.com/File UploadDrag and Drop (or) Choose FilesFor Uploads over 8MB, please use one of the free of charge file transfer services for example https://wetransfer.com/Quote Required *Please chooseYesNoPlease Note: Quotes are only valid for 30 days if quote expires, cancellation fee will apply. *UnderstoodPre-Approved AmountIs a purchase order/service request required *Please chooseYesNoFile Upload *Drag and Drop (or) Choose FilesFor Uploads over 8MB, please use one of the free of charge file transfer services for example https://wetransfer.com/All work requested has been discussed with and has the consent of the consumer and/or their carer. Consumer is aware of the $55.00 cancellation fee should the requested work not proceed or if the referral is cancelled 24 hours after submission *YesName of Person Submitting Referral *Phone Number of Person Submitting Referral *Please send a copy of this form submission to Submission Date *SUBMIT FORMPlease do not fill in this field. Please do not fill in this field.