Home Visit Checklist

Complete this form to organise a home visit
Please complete this form

Client Details

Tell us about getting to your address

This information will help us prepare for our visit to your home.

Is the street sign visible?
Is there difficulty finding the property or the number?
Is the gate difficult to open?
Are there any dangerous or slippery steps?
Is the client able to open the door?
Is there mobile reception?

Tell us what it's like inside your address

Is there adequate lighting?
Are there any trip or clip hazards?
Are smoke detectors present and maintained?
Are there any known weapons or firearms in the house?

Tell us about the occupants at your address.

Are there any known infectious illnesses in the house? (gastro, measles etc)
Has you or anyone in the house returned from overseas or interstate in the last 14 days?
Have you or anyone in your home had any contact with a current or suspected case of COVID-19 (Coronavirus)?
Does the client have any pets/animals around the house?
Does the client or do other occupants smoke?
Have communication methods with the client been established?
Are there any other occupants or visitors likely to be presents during home visits?
Is there known substance abuse amongst the occupants or the visitors?
Does the client, or other occupants have a history of violent or aggressive behaviour?

Extra information and consent

Suite 7/32 Bayfield Street
Rosny TAS, Australia
1a 75 Paterson Street
Launceston TAS, Australia 
Phone: 1300 326 172
Contact Us
Office Hours:
Mon - Wed8am - 6pm
Thur & Fri8am - 5pm
© Copyright MouthWorks Therapy Centre 2021
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