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

What are the prospective resident's living arrangements?*

Prospective resident's current location*

I am*

Planning to make an immediate application
Researching options for the future

I am enquiring about*

Short-term respite care
Permanent care

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

Yes
No

Do you have a referral code for permanent / respite 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- or 2-

Referral code for permanent care*

Referral code for respite care*

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.

Are you a recipient of NDIS?*

Yes
No

Are you a Helping Hand Home Care client?*

Yes
No

Are any of the following legal documents in place?*

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

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

Select as many as you like

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

This field is for validation purposes and should be left unchanged.

Residential Care Home Expression of Interest Form