Forest Allied Health Support At Home Registration Form
Name
*
First Name
Last Name
Date of Birth
*
Phone /Mobile
*
Email
Address
Street Address
Street Address Line 2
Suburb
State
Postcode
Support Person
First Name
Last Name
Support Person Email
Support Person Phone
Living with client yes/no
Preferred Contact
*
Client
Support Person
Both client and support person
Other
Therapy Services Required
*
Occupational Therapy
Physiotherapy
My Aged Care Number
Support At Home Provider
Support At Home Case Manager Name
Support At Home Case Manager Email
GP Name
GP Phone
-
Area Code
Phone Number
Disability / Diagnosis
Other Medical History
Reason for Occupational Therapy Assessment - please provide as much detail as possible
*
Client /care manager identified AT-HM Scheme Needs (please tick all that apply). Please note clinical assessment by Occupational Therapist will determine any neccesary and clinically justifed prescription
*
HM-AT Assessment and Presciption
Low-cost Equipment items (shower chair, walking frame, toilet raiser) (pre-approval required)
Mid-cost AT Higher-cost Equipment Items (electric lift chair, standard wheelchair)
High cost AT (hospital bed, pressure mattress, power wheelchair) etc.
Minor Home modifications (e.g. shower grabrails, threshold ramps)
Major Home Modifications (e.g. structural modifications, large ramps) - NOT PROVIDED BY FOREST ALLIED HEALTH
Support At Home AT-HM Scheme Funding Tiers (if known)
Other Comments
Confirm Email
*
URGENT
YES
NO
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