Household Help Services Needs Assessment and Consent form Household Help Services Needs Assessment (HHSNA) and Consent Form PhoneThis field is for validation purposes and should be left unchanged.You have been referred to Recovery Partners to complete a Household Help Services Needs Assessment. About Recovery Partners Recovery Partners have been engaged to conduct an independent assessment of your current functional capacity and how your injury or condition impacts your ability to complete activities within your home. Our role is to assess and document your current abilities, identify any barriers affecting your independence, and provide recommendations to the referring organisation. We do not make decisions regarding claim liability, funding or treatment approval. What to Expect During the Assessment The assessment will typically take place in your home and take approximately 60–90 minutes. Before your assessment, you will be sent questionnaires to complete and return prior to the appointment. During the assessment, the consultant may: • Discuss your medical history and current symptoms. • Review how your injury or condition affects your daily activities. • Ask questions about your home environment and support systems. • Observe you completing selected daily tasks where appropriate and safe to do so. • Assess your functional abilities, including mobility, self-care and household tasks. • Discuss strategies, equipment, or supports that may assist you to maximise your independence. Your participation is voluntary; however, the assessment findings are based on the information provided. Photographs As part of the assessment, photographs may be taken of relevant areas of your home environment, equipment, or task set-ups to assist with documenting assessment findings and recommendations. Photographs will: • Be used solely for assessment and reporting purposes. • Be stored securely in accordance with privacy requirements. • Not be used for any other purpose without your consent. Please indicate your consent below.Please indicate your consent for photographs being taken during your assessment:* I consent to photographs being taken during the assessment. I do not consent to photographs being taken during the assessment. Home Safety Information To assist us in ensuring the safety of both yourself and our consultant, please advise if any of the following apply:Dogs or animals are present at the property:* Yes No If yes, please provide further details:* Please ensure any animal on the property is placed in another room or outside during the home visit (unless a guide/assistance animal).Are there any access issues, such as locked gates, steep or uneven pathways, or difficult property access?* Yes No If yes, please provide further details:Are there any known safety hazards within the home or property?* Yes No If yes, please provide further details:Are there any other circumstances that may impact the safety of our consultant during the visit?* Yes No If yes, please provide further details:Consent I acknowledge that: • I have read and understood the information provided above. • I understand the purpose of the assessment and Recovery Partners’ role. • I agree to participate in the assessment. • I understand that the assessment findings and report will be provided to the referring organisation. First Name*Last Name*Signature*Date* If you have any questions prior to the assessment, please contact Recovery Partners on 1300 647 789 or admin@rrp.com.au.
