Enquiry no.
Referring organisation
Contact person
Telephone
Mobile
Email
Address
Type of organisation Please select Local Authority/NHS Trust Housing Association Private individual/Organisation Voluntary organisation Agency Charity Case Management Co.
Service user name
Date of birth
Reason for referral
Present situation (social situation, ownership of property, benefits/allowances, and other background information)
Medical condition, including name/address/telephone number of GP (if known)
WHAT TYPE OF ASSESSMENT/REPORT IS REQUIRED (PLEASE TICK AS NECESSARY)
Activities of daily living - bath/kitchen/chair/stairs/other
Housing - major adaptation/re-housing assessment
Case Management
Medico Legal
Transport assessment
HEALTH AND SAFTY (PLEASE INDICATE TYPE OF ASSESSMENT REQUIRED) Risk assessment/Moving and handling Ergonomic/Workstation assessment Vocational rehabilitation/Return to work assessment Specialist assessment - please give details
CARE HOMES/RESIDENTIAL UNIT Individual assessment Group assessment Complaints/appeals
Training - please give details
HOW MUCH INPUT IS REQUIRED?
Assessment and report Assessment, report and follow-up visit Assessment, report, follow-up visit and ongoing treatment programme
When is report needed?
TO WHOM DOES THE REPORT NEED TO BE SENT?
Name/Title
Please indicate your preferred method of receiving report Email Fax Post
Do you have any special requirements (Medical/Legal advice/Photos etc.)?
Will you be providing paperwork to Access Independent prior to the assessment taking place (i.e. copy of previous/present reports, medical information)? Please select Yes No
Who is funding referral (i.e. service user/organisation/other source i.e. insurance company)?
Is client aware of request? Please select Yes No
How did you hear about Access Independent? Please select Google Access Independent website OT recommendation College of OTs OTIP Other (please give details...) If 'Other', please give details here
ENQUIRY FORM
ENQUIRY FORM