Online Home Care Package Referral for Major Modifications

Home Care Package Major Modifications Referral Form

For Home Care Package Major Modifications (over $3,300.00)
Title*
First Name*
Surname*
Preferred Name
Date Of Birth

DayMonthYear
Street Address*
Suburb and Postcode*
Postal Address (if different from above)
Suburb and Postcode
Phone*
Mobile
E-Mail
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*
Postal Address*
Suburb and Postcode*
Phone*
Mobile
E-Mail*
E-Mail Address for Quotes (if different from above)
E-Mail Address for Tax Invoices (if different from above)
Occupational Therapist Name*
Occupational Therapist Organisation*
Phone*
Mobile
E-Mail*
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.
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 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.

Yes
Acceptance*

I 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
Name of Recipient*
Date*

DayMonthYear
Signature

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Home Care Package Major Modifications Referral Form