Residential Care Expression of Interest

Contact Person's Details

Title*

First Name*

Last Name*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone Number*

Alternative Phone Number

Email

Your relationship to the prospective resident*

Prospective Resident's Details

Title*

First Name*

Last Name*

Date of Birth*

DD/MM/YYYY

Gender*

Marital Status*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Prospective resident's current location*

I am enquiring about*

Short-term respite care
Permanent care

I am*

Planning to make an immediate application
Researching options for the future

I would like to receive an application pack by post*

Yes
No

Which of our residential care homes are you interested in?*

Select as many as you like

Clare
Golden Grove
Ingle Farm
Jamestown
Lightsview
Mawson Lakes
North Adelaide
Parafield Gardens
Port Pirie

Have you had an assessment by the Aged Care Assessment Team (ACAT)?*

Yes, prior to April 2016
Yes, after April 2016
No

Do you have a referral code for permanent care from My Aged Care?*

This number can be found on your My Support Plan, in the section that details approval for Residential Permanent. It is a 12 digit number, that starts with 1-

Referral code for permanent care*

What is the prospective resident's Medicare number?*

If the approval for permanent residential care was given prior to April 2016, we will need the applicant's Medicare number to gain access to the aged care record. Please include the applicant's position on the Medicare card.

Please contact My Aged Care on 1800 200 422 to arrange an aged care assessment. Approval through an aged care assessment is required before an applicant can move in to a residential aged care home.

What are the prospective resident's living arrangements?*

Are any of the following legal documents in place?*

Enduring Power of Attorney
Enduring Power of Guardianship
Medical Power of Attorney
Advance Care Directive
No legal documents in place

How did you hear about Helping Hand?*

Please provide some additional details about your expression of interest.

Helping Hand is bound by the National Privacy Principles in the Privacy Act 1988. These principles regulate the way we handle personal information about you. A copy of our Privacy and Confidentiality Policy can be found at http://helpinghand.org.au/resources/policy-and-position-statements/

Phone

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Residential Care Home Expression of Interest Form