CHM This short questionnaire is designed to help us

understand your situation and guide the next steps.

There’s no obligation - just clear, supportive guidance.

Q1. Who is the home modification for?

Myself

My child

A family member

Someone I support professionally

Q2. What best describes your current situation?

Recently discharged / preparing to leave hospital

Living at home but experiencing access or safety issues

Disability or needs have changed

Planning ahead

Not sure - just exploring options

Q3. Are you currently an NDIS participant?

Yes - approved

Awaiting approval

No

Unsure

Q4. Are you currently working with an Occupational Therapist (OT)?

Yes

No

Not yet

Q7. Is there anything you’d like us to be aware of?

Your Name *

Your Email *

Your Phone

Thank you for taking the time to complete this.

We’ll review your responses and be in touch to talk through what may be possible - at a pace that feels right for you.

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Let’s Start with What You Need

Thank you for taking the time to complete this.