Occupational Therapy & Home Modifications in Kalgoorlie

Home Modification Request

Client details

First Name

Last Name

Client ID

Contact number

Gender

Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

Client Contact Person - Optional

First Name

Last Name

Contact number

Therapist Details

All clinical forms creation and amendments must be conducted through the documentation control process

Occupational Therapy Assessment completed on

First Name

Last Name

Contact Number

Program

NDIS (National Disability Insurance Scheme)

Aged Care Package

DVA (Dept of Veterans Affairs)

GEAT (Goods, Equipment, and Assistive Technology)

TCP (Transition Care Program)

CHSP (Commonwealth Home Support Program)

Private

Rental

Yes (If yes, consent from owner has been confirmed and documented in Comcare - Consent required)

What rental equipment do you require

Client goals linked to this home modification

Alerts/Additional Information

Home Modification Recommendations

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Please note:

Recommended home modifications accord with Australian Standards 1428.1, 2021, unless documented otherwise above.
Placement of home modifications may vary according to existing building materials, i.e. position of studs, fixtures, etc.
Any queries please contact the referring Occupational Therapist.
All measurements are in mms and diagram not to scale.

Disclaimer:

The recommendations outlined are based on the client’s function, habitual movement patterns and anthropometrics and are made in conjunction with the client/homeowner. They do not purport to reflect other than limited knowledge, on the part of the Occupational Therapist, of structural considerations and the building codes. ALL responsibility for installation of home modifications (structural considerations, compliance with building codes, quality and workmanship of work) rest with the installer. Kalcare accepts NO responsibility or liability in connection with the installation of home modifications.

I have read and agree to the Disclaimer above.

Occupational Therapy Home Modification

Client details

Client Contact Person - Optional

Therapist Details