Minor Modifications HCP and STRC Home Maintenance - Home Assist Community Services

HCP and STRC Brokerage

To be completed by Home Care Package providers for requests
To be completed by Occupational Therapists for minor modification requests

Form Reference 00

Date of Referral *

Type of Referral *

Occupational Therapist Name *

Occupational Therapist Business *

Occupational Therapist Email *

Occupational Therapist Phone Number *

Does the Person have a Home Care Package or STRC? *

STRC start Date *

STRC End Date *

Title *

First Name *

Surname *

Preferred Name

Date of birth *

Country of Birth *

Language spoken *

Street Address *

City *

Postal Code *

Phone Number *

Mobile

Additional Contact Person

Phone

Relationship to Client

Consent to act on behalf of consumer

Residency Type *

Owner / Landlord / Agency Name (if applicable) *

Owner / Landlord / Agency Postal Address

Suburb and Postcode

Phone *

Mobile

Dwelling Details *

HCP/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 Files

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

File Upload

Drag and Drop (or) Choose Files

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

File Upload

Drag and Drop (or) Choose Files

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

Quote Required *

Please Note: Quotes are only valid for 30 days if quote expires, cancellation fee will apply. *Understood

Pre-Approved Amount

Is a purchase order/service request required *

File Upload *

Drag and Drop (or) Choose Files

For 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 *Yes

Name of Person Submitting Referral *

Phone Number of Person Submitting Referral *

Please send a copy of this form submission to

Submission Date *

Please do not fill in this field.

133 Adelaide Street Maryborough 07/4123 2234

07 4123 2234

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HCP and STRC Brokerage

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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

HCP and STRC Brokerage

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)