Client Registration Form

Registration Form
Angel Assist is an introduction service that finds Angel Assistants (helpful housemates) to support people in need of a helping hand. In return for a maximum of 14 hours of help a week, Angel Assistants receive free food and board. If you need more hours, it is possible to arrange the Carer's Pension for the Angel Assistant, depending on your financial circumstances. The candidates don't necessarily have experience or qualifications in caring, as long as they are able to help with basic life skills such as cleaning. The types of duties may vary significantly and will depend on your exact needs.

We have multiple candidates on offer to suit all types of needs and in various locations around Australia. Our screening process starts with this form to ensure that every candidate we present to you is the best possible match for your needs and routines.

Please fill in the following registration form with as much detail as you can so we can match you to the best possible Angel Assistants for your needs.
Your Name*

First NameLast Name
The remaining questions are not marked as required, but help us find the best Angel Assistant for your needs. Your privacy is taken very seriously at Angel Assist. All information you share with us will only be used for the purpose of finding an Angel Assistant. Please feel free to skip any questions you don't feel comfortable with.
MaleFemaleOther
Your phone
Include area code if a land lineFormat: 00 00000000.
Your email
example@example.com
GoogleWord of mouthCareseekers.com.auCommunity CentreMediaAngel Assist websiteAu Pair Me Up websiteMy NDIS providerMy Home Care Package providerBarkSales repOther
Name of sales rep:
For myselfFor someone else
12Other
I am their childI am their grandchildI am their parentSiblingSpouseFriendLegal guardianOther
AdelaideBrisbaneCanberraDarwinGold CoastHobartMelbournePerthSunshine CoastSydneyPort MacquarieOther
Address of the person / people requiring help
Full name of the first person requiring help

First NameLast Name
MaleFemale
Roughly how old is the first person needing help?
Full name of the second person requiring help

First NameLast Name
MaleFemale
Roughly how old is the second person needing help?
What languages other than English are spoken in this home?
Yes - this is essentialThis is preferable but not essentialNo
Which other language/s?
YesNo
YesNo
YesNo
SmokeVapeSoft drugsHard drugsNone of the aboveOther
Doesn't drink1-2 drinks per week3-5 drinks per week5+ drinks per week
YesNo
CatsDogsHorsesSnakesBirdsOther. Please type here.
YesNo
Dietary requirements:
Old ageMental illnessMental impairmentPhysical impairmentUses a mobility walkerCan't be left aloneHigh risk of fallsOther
No signs of dementiaStarting to forget some thingsRepeats themselves frequentlyAt risk of getting lostShould not be left alonePotentially a danger to themselvesPotentially a danger to othersIs now forgetting familiar peopleAlmost non-verbalOther

What types of help would you like from the Angel Assistant?

Rows	Not required	Sometimes	Often needed	Essential
Companionship
Cleaning
Laundry
Shopping
Assistance with feeding
Showering / hygiene / help going to toilet
Blood pressure / blood sugar monitoring
Prompting for medications
Help attending health appointments
Driving
Help with dementia
Help with physical impairments
Assistance with depression / anxiety / anger
Basic home maintenance (eg mowing, gardening)
Cooking
Heavy lifting
Support due to mental impairment
Supervision in case of accident / falls

Please describe in detail your circumstances and the kind of help you require.
Private bedroomDoor lockSingle bedQueen bedKing bedBedside tableLampWalk in robeCupboard / WardrobeDrawersDeskChairGranny flatOwn separate living areaOwn kitchen / kitchenetteCouchTelevisionPrivate ensuiteShared bathroomAir-conditioned bedroomFan in bedroomHeaterOff-street parkingFree wifi / internetNetflix / other tv subscriptionsWalk to public transportWalking distance to shopsPoolUse of a carWalk to beachWalk to forest / bushland / nature reservesWalk to CBDOther
How many bedrooms are in the house the Angel Assistant would be living in?
How many bathrooms are in the house the Angel Assistant would be living in?
How would you describe the home that the Angel Assistant would be living in?
Do you have any photos of the home and room?

Cancelof
YesNo
Besides the person / people requiring care, who else be living in the home?
Do you have any photos of the people living in the home you'd like to share?

Cancelof
This next section identifies your preferences in terms of what type of candidate you are looking for. Since Angel Assist gets numerous applications every day from candidates, we use our own unique algorithm to filter the appliants against your requirements. This ensures that we present you with only the most compatible candidates for your family's needs.
MalesFemalesOther
CouplesSomeone with a child/childrenSmokersStudents - Mostly onlineStudents - Mostly on campusBackpackersRetireesFull-time workersPart-time workersUnemployed/welfare recipientsSomeone requiring special dietary requirementsPet dog/sPet cat/sSomeone with any types of petsSomeone who is presently homeless / experiencing extreme housing stressOther
What qualities are important to you when selecting a candidate?
Aged careHealthSpecial educationDisability careOther
What date would you like the successful applicant to start?

DayMonthYear
14 or less15 to 2829 to 40
Business hrsNightsWeekendsAnytime - we need someone who is very flexibleIt doesn't matter when they workOther
Angel Assist offers a unique form of care by helping aged and vulnerable people receive assistance in their home from a live-in Angel Assistant. In return for up to 14 hours of active support, the live-in Angel Assistant would receive free food and board.

In some circumstances, Angel Assistants may be eligible to receive the carer's pension and/or carer's allowance and supplement. This can go a long way towards making home care affordable for those who need it most.

For your Angel Assistant to be eligible for the carer's payment, the person requiring care must meet the following criteria:
- They must be either an Australian citizen or permanent resident in Australia.
- They must be receiving constant care either in their own home or in their carer's home.
- They must have a high level of need (to be confirmed by a doctor).
- Their assets (excluding their place of residence) must be less than $744,000.
- Their income must be less than $120,605 per year.
YesNo
YesNo
Pension (of any sort)NDIS (National Disability Insurance Scheme)Home Care PackageCommonwealth Home Support Package (CHSP)Other
Yes, currently receiving itYes, but still waiting to receive itYes, but currently waiting to be upgradedNo - but have appliedNo, haven't appliedOther
Level 1 (Needing the least amount of care)Level 2Level 3Level 4 (Needing the most amount of care)Not sure
The help-recipient also lives with other family members / caregiversFamily lives close by and will drop by regularlyThere are also paid professional carersSecurity camerasEmergency alarmsSoftware / an app / journal to manage requirements and communicationRegular unannounced visits from friends / familyWE NEED FURTHER ASSISTANCE WITH THISOther
The help-recipient has not yet been toldThe help-recipient is not yet fully convincedThe help-recipient is currently away in hospital / respite etcAdditional family members have not yet agreedThe room / house still needs to be cleaned / arrangedEVERYTHING HAS BEEN PREPAREDOther
YesNo
NDIS fundsHome Care Package fundsNone of the above
What is the full name of the care recipient whose funds will be used to pay for the Angel Assist's fee? (This is so we can invoice you correctly to potentially allow your government funding to pay for our fee)

First NameLast Name
Registration Completed

MonthDayYear
Hour MinutesAM/PM Option
Electronic Signature

First NameLast Name
Authorisation

By clicking the submit button, I authorise Angel Assist to start looking for suitable candidates that match the requirements specified above. I certify that the facts contained in this registration are true and complete to the best of my knowledge.

I understand that Angel Assist's fee for finding and screening a suitable Angel Assistant is $2,999. This fee is payable over installment periods agreed to prior to placement. The first installment is payable following the satisfactory start of an Angel Assistant.

I understand that Angel Assist guarantees to find a suitable candidate that lasts at least 3-months from the time the Angel Assistant moves in, and that if the chosen Angel Assistant does not work out in this time that they will be replaced free of charge. I understand that this service fee is not refundable if I change my mind about having an Angel Assistant or if the circumstances of the help-recipient change before the end of the 3-month guarantee period.

I understand that Angel Assist is an agency that facilitates the introduction of Angel Assistants (helpful housemates) with families. The arrangement constitutes a housemate agreement between the Angel Assistant and the Host, and is not to be an employment agreement. Angel Assistants are to receive free food and board in return for abiding by predetermined "house rules" that include 14 hours of active help per week. Angel Assistants must not be paid for their services. It is imperative that the hours do not exceed 14 hours unless provision has been made for the Angel Assistant to receive the Carer's Payment and the increase in active hours has been mutually agreed between both parties.

As an introducing agent, Angel Assist is not party to any agreements that are made between the Angel Assistant and the Host. No representative of the company has any authority to enter into any agreement for employment for any specified period of time, or to make any agreement contrary to the foregoing, unless it is in writing and signed by an authorised company representative. While Angel Assist will undertake standard screening checks to verify the information provided by candidates, the Host is ultimately responsible for deciding on the final candidate and for overseeing the arrangement.

In providing the introduction service, Angel Assist is not liable for the actions of either the Host or the Angel Assistant or any of their delegated parties. The person submitting this form authorises that they have the necessary legal capacity to make decisions on behalf of the persons listed on this form as requiring care. This online application does not permit the release or use of information in a manner prohibited by the Privacy Act (1988) and other relevant federal and state laws.
I agree
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