Request for household help services

Use this form when referring an injured worker for household help services.


What it contains

A form that can be completed by a physiotherapist, osteopath, chiropractor or medical practitioner who is currently providing treatment to the injured worker.

This information is essential for an agent to make timely, informed decisions around an injured worker's eligibility for household help services. We encourage you to provide as much detail as possible to assist agents in determining eligibility.

Once completed and signed, provide this form to the injured worker or to the agent case manager directly.

Please ensure that the Household help: worker's declaration is reviewed and agreed to when completing this request form.