Home Modifications referral

Home Modifications Building Referral Form

Welcome to Hunter Home Modifications Building Referral page. Please complete the form below to submit a referral to our building service for a home modifications quote or to arrange a joint builder visit. Please note, the information collected is to ensure that we have the required details to effectivley provide service to you and/or your client.
This information is not disclosed outside of our organisation without your permission.

Referral Date *

Referrer Details

Referrer Given Name *

Referrer Surname *

Agency/Relationship *

Days Worked *

Referrer Phone Number *

Referrer Email Address *

Is the client aware of this referral and consents to the referral? *

YesNo

Treating OT Name

Treating OT Phone number

Treating OT Email

Client Information

Given Name *

Surname *

Date of Birth *

Phone Number

Email Address

Street Address *

Suburb *

State

Postcode *

Is the client the main contact? *

YesNo - Alternative Contact

Alternative Contact Person

ReferrerOtherNone

Contact Given Name

Contact Surname

Relationship

Contact phone number

Contact Email

Property information

Please specify "other" accomodation type

Housing detailsPlease provide housing provider information including name and number.

Landlord/Strata Permission

Browse

Please note that the referral will not be processed for quoting without a completed landlord approval. The referrer or client will need to arrange for this to be signed and returned to Hunter Home Modifications. If you would like a copy of our landlord form please see https://homemodificationservice.org/forms-specifications/

Household *

SingleCoupleFamilyOther

Property Type *

HomeUnit/apartmentDuplexOther

Funding Details

Funding Agency *

Commonwealth Home Support Program (CHSP)/ My Aged CareNational Disability Insurance Scheme (NDIS)Support at HomePrivate Referral

Is the client known to My Aged Care and do they have a home adjustments (previously known as home modifications) referral code? *

YesKnown to My Aged Care but no home modifications codeNo

Client's My Aged Care NumberIdentification number provided by My Aged Care that starts with "AC"

Referral CodeThe referral code needs to be for "home modifications" service type. If the client has a code but does not know the code the referrer will need to contact My Aged Care (with client) to retrieve this information. If HHM already has the home modifications referral please indicate this.

Please note that Hunter Home Modifications is unable to action the home modifications request without a "Home Modifications" referral code from My Aged Care. Please ensure that the referer or client has contacted My Aged Care on 1800 200 422 to arrange for the referral code to be generated and sent to Hunter Home Modifications. A quote will not be generated until Hunter Home Modifications has received this code.

Is the client receiving a home care package? *

YesNoUnsure

Case Manager Details *

ReferrerOther

Please provide Case manager details including name, phone number and organisation. Also please indicate level of Home Care Pacakge (1,2,3 or 4) they are currently receiving and thier approved level *

NDIS number *

Home Modification Funding *

Agency ManagedPlan ManagedSelf-managedUnsure

Funding Available Under *

Core supports - Low Cost ATCapital Supports - Home Modifications Unsure

Plan Manager Details

Please provide COS or LAC contact detailsPlease provide contact details including name, phone and email for the client's COS or LAC.

Data Exchange Information

Country of Birth

Language Spoken

Home Modifications Request

Modification Type *

Minor ModificationsMajor Modifications (major bathroom, ramp, steps with landing) Minor and Major ModificationsBuilder Consult Visit or Builder Practitioner Visit

Builder Consult Completed *

YesNo

Building Service *Please provide details of the building service

List of required modifications *Please list in order as the modifications appear on the plans and specifications document

Please attach photos, drawings and specifications for each modifications *

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Please ensure all referrals have accompanying photos of the area to be modified with CAD drawings and specifications. If you require a copy of the specifications templates or would like to see an example attachment of plans, please see https://homemodificationservice.org/forms-specifications/

Quote to be sent to (multiple available) *

ClientAlternative contactReferrerOther

Other quote recipientName, phone number, relationship to client and postal/email address

Further Information

Further information regarding the client/ referral