Care Application Form

For Respite or Permanent care

Before you complete this form please make sure you have the following documents ready to upload.

1. Copy of Aged Care Assessment / My Support Plan
2. Current Health Summary supplied by your doctor
3. Copy of Residential Aged Care Fees Letter including attachment of Assets Summary
4. Enduring Power of Attorney
5. Completed Statement of Choices A or B OR Advanced Health Directive
6. Copy of Home Care Client Balance Statement (if applicable)

Please Indicate:(Required)

Application for Permanent Care Position

Application for Respite Care Only

Respite and Application for Permanent Care Position

Personal Details

Name(Required)

Title First Middle Last

Preferred Name

Gender(Required)

Male

Female

Date of Birth(Required)

Marital Status(Required)

Home Address(Required)

Street Address City State / Province / Region ZIP / Postal Code Country

Postal Address (If different to home address)

Street Address City State / Province / Region ZIP / Postal Code Country

Email(Required)

Enter Email Confirm Email

Contact Phone Primary(Required)

Alternate Phone Contact(Required)

Religion(Required)

Please advise of any cultural or religious requirements, such as specific dietary needs.

Aboriginal or Torres Strait Origin(Required)

Yes

No

Country of Birth(Required)

Language(s) Spoken(Required)

Do you need an interpreter to help with your everyday English(Required)

Yes

No

2. Nominated Representative

If you would like The Home to contact a representative on your behalf about this application or placement, please provide details below. If you are nominating a person who has legal authority to make decisions for you, please advise the type of authority they have, and attach a copy of the authority to this application.

Name

First Last

Address

Street Address City State / Province / Region ZIP / Postal Code Country

Contact Phone Primary(Required)

Alternate Phone Contact(Required)

Email(Required)

Enter Email Confirm Email

Relationship to you(Required)

Type of Authority(Required)

3. Next of Kin (first contact)

Same as the nominated representative above(Required)

Yes

No (please add details)

Name

First Last

Address

Street Address City State / Province / Region ZIP / Postal Code Country

Contact Phone Primary(Required)

Alternate Phone Contact(Required)

Email(Required)

Enter Email Confirm Email

Relationship to you(Required)

4. Next of Kin (second contact)

Same as the nominated representative above(Required)

Yes

No (please add details)

Name

First Last

Address

Street Address City State / Province / Region ZIP / Postal Code Country

Contact Phone Primary(Required)

Alternate Phone Contact(Required)

Email(Required)

Enter Email Confirm Email

Relationship to you(Required)

5. Other Details

Pension Details

Do you receive a pension?(Required)

Yes, I receive a full pension

Yes, I receive a part pension

No, I do not receive a pension

If yes, which do you receive?

Centrelink Payment

Department Veterans’ Affairs payment

Pension Card Number

Expiry Date

If you receive a Department Veterans’ Affairs pension what colour is your card?

Medicare Details

Your Name as it appears on the card

Card Number

The number that appears on the left of your name i.e., 1,2

Expiry Date

Diabetes Number if applicable (NDSS)

Home Care Details

Are you / have you ever received Home Care services?

Yes - please provide balance of Income Tested Care Fees paid (Balance Statement)

No

Private Health Insurance Details

Name of Fund

Membership Number

Level of Cover

Expiry Date

Funeral Preferences

Preferred Funeral

Burial

Cremation

Undecided

Funeral Preferences Details e.g., Funeral Director etc.

Do you have an Advance Health Directive or Statement of Choices Form A or Form B

Yes - please attach a copy with this application

No

Do you have any Allergies

Yes

No

Please Provide Allergy Details

Medical Contact Details

General Practitioner

Address

Street Address City State / Province / Region ZIP / Postal Code Country

Phone

Other Health Professional - Specialist Field i.e., Audiologist, Heart Specialist

Chemist

6. Type of Accommodation

Please indicate the type of accommodation you require

Concessional/Assisted Resident (Assets under $175,239.20) Effective 1st January 2022

$330,000 RAD or equivalent

$400,000 RAD or equivalent

$450,000 RAD or equivalent

$475,000 RAD or equivalent

Are you interested in Extra Services Accommodation?

Yes

No

Please upload the following documents

1. Copy of Aged Care Assessment / My Support Plan
2. Current Health Summary supplied by your doctor
3. Copy of Residential Aged Care Fees Letter including attachment of Assets Summary
4. Enduring Power of Attorney
5. Completed Statement of Choices A or B OR Advanced Health Directive
6. Copy of Home Care Client Balance Statement (if applicable)

Upload Documents(Required)

Drop files here or

Accepted file types: doc, docx, pdf, png, jpg, Max. file size: 512 MB.

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