Medical Assessment
This form is to be completed by the client's health care professional to provide information about the client's medical
condition. Page 1 is to be completed by the client and the health care professional is to complete page 2 onwards.
Please use BLOCK LETTERS and print in black or blue pen only. Please mark all relevant boxes with a
. If you
need more space, please write on a blank page and attach it to this form. For information or assistance with this form,
phone 1300 468 746, 24 hours a day, 7 days a week.
Client reference number
T-File number
Application reference number
Payment reference number
Name of social housing provider
Client details
Title
Mr, Mrs, Ms, Miss
Last name
or family name
First and middle name(s)
Street/Avenue
Unit/House number
Postcode
Town/Suburb
FACS Privacy Notice
This privacy notice applies to the Department of Family and Community Services (the Department). The Department
together with its related agencies complies with NSW privacy legislation when collecting and managing personal and
health information. The information we collect from you or from an authorised third party will be held by the program that
collects it. It will be used to deliver services and to meet our legal responsibilities. We may also use your information
within the Department as a whole to plan, coordinate and improve the way we provide services and may exchange your
information with other social housing providers for the purpose of assessing your continuing eligibility for social housing
and providing an appropriate service. The Department is also legally authorised to disclose information to outside bodies
in certain circumstances.
Further information about your privacy rights can be found on the Departments website: www.facs.nsw.gov.au/
site_information/privacy or by calling: 02 9377 6000 or by emailing: privacy@facs.nsw.gov.au.
Notice: Your personal information and any relevant health information provided on this form will be exchanged between
social housing providers (public, community and Aboriginal housing) for the purpose of assessing your continuing
eligibility for social housing and providing an appropriate service.
Authorisation
I have read and understand the above notice.
I give permission for medical details affecting my need for housing to be released to the above named social
housing provider and, if necessary, for my doctor/health care professional to discuss these details on my behalf with
the social housing provider.
Signature
Date
DH3008 04/15
DD/MM/YYYY
Page 1 of 6
To the health care professional
The client has presented to the social housing provider requesting housing assistance. Social housing providers are
committed to allocating suitable housing and creating sustainable tenancies. When completing this form it is important to
take into account that information you provide will be most helpful to the client if it reflects your professional opinion.
The information you provide will assist in accurately assessing the clients housing need, including particular housing
features, such as type or location.
To assist in this process the following information is required.
Details of health care professional completing this form
Title
Mr, Mrs, Ms, Miss, Dr
Last name or family name
Organisation Name
Unit/House number
Street/Avenue
Town/Suburb
Postcode
Phone
Mobile
Email
Provider number
1.
Please describe the professional
service you provide to the client.
General practitioner
Specialist
Other
Allied health worker
give details
2.
Please describe your field of expertise.
3.
How long has the client been one of
your patients?
DH3008 04/15
One consultation
only
Weeks
Months
Years
Page 2 of 6
4.
Please provide details of the clients
medical condition and the affects it has
on both their housing needs and their
ability to access and sustain housing.
Name of medical condition(s)
Description of condition(s)
How the condition(s) affects the clients
housing needs
Frequency of visits to the practitioner
Overall impact of the condition(s) on the
clients wellbeing (please tick)
Minor
Moderate
Severe
Long
(5 years or more)
5.
What is the likely duration of the
condition(s)? (please tick)
Short
(0 - 2 years)
Medium
(2 - 5 years)
6.
Do any of the above medical conditions
restrict the client from accessing the
required health service by walking or
taking public transport?
Yes
No
Go to 7.
give details
Is the clients current accommodation
exacerbating their medical
condition(s)? (e.g. lack of room for
specialised medical equipment)
No
Go to 8.
give details
No
Go to 9.
7.
8.
Is the clients mobility restricted?
Yes
Yes
give details
DH3008 04/15
Page 3 of 6
9.
Can the client manage steps/stairs?
No
Yes
Go to 10.
if yes, how many
10. Does the client need accommodation
that is modified? (e.g. hobless shower,
1/4 turn taps, wheelchair access)
11. Does the clients condition(s) affect
their ability to look for suitable
private rental accommodation?
12. Does the client have extra expenses
because of their medical condition(s)?
13. Does the client need to live in a
particular area to access
support services?
14. Has an independent living skills
assessment been done?
15. Is the client able to live independently
without support?
1-2
3-5
Yes
No
Go to 11.
No
Go to 12.
No
Go to 13.
No
Go to 14.
No
Go to 15.
6 or more
give details
Yes
give details
Yes
list the expenses
incurred on a regular
basis which may cause
financial hardship to
the client
Yes
what location
is required?
Yes
attach the
independent living
skills assessment
Yes
Go to 16.
No
tick required support
DH3008 04/15
Personal care
Cooking
Shopping
Cleaning
Financial
management
Identifying
unsafe
situations
Other
give details
Transport
Page 4 of 6
16. Does the client currently have support
for these functions?
Yes
No
Go to 17.
Go to 19.
name of support
person/provider
17. Does the client currently have a carer?
Yes
No
18. Is the carer (please tick)
Part time
Full time
18a. Does the carer live with the client?
Yes
No
Go to 19.
19. Do psychological issues affect the
clients ability to cope?
Yes
No
Go to 23.
20. Does the condition(s) require
medication for the client to
live independently?
Yes
No
Go to 21.
No
Go to 22.
21. Is the clients condition(s) supported by
other health professionals?
On a needs
basis
give details
Yes
tick all that apply
Mental health
workers
Counsellors
Psychiatrists
Other health professionals
give details
22. Does the client have a particular
dwelling requirement as a result of
the condition(s)?
23. Would you like to add further
comments to support the
clients needs?
DH3008 04/15
Yes
No
Go to 23.
No
Go to checklist.
give details
Yes
give details
Page 5 of 6
Checklist
If appropriate, have you attached copies of
relevant documentation such as:
Independent living skills assessment
Occupational Therapists report detailing required modifications
Other documentation
give details
Practitioner's name
Signature
Date
DD/MM/YYYY
Thank you for taking time to complete this form
DH3008 04/15
Page 6 of 6
