Accommodation Application

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Christmas closure information, please read.

Leukaemia Foundation Offices will be closed from close of business on Friday 23 December 2022 and will re-open again on Tuesday 3 January 2023.

Forms submitted during this time will be actioned once we re-open.
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Changes to this form, please read.

We have recently made some changes to this online accommodation application form, these changes have been made in line with amendments to our assessment process, as well as some changes to the way we offer accommodation support.

If you have completed this form before, you may notice some questions have been removed or changed, to allow for faster completion of this form and ease of use for the applicant. Some of these questions have been removed to allow further assessment to be done over the phone by our team.

Should you have any questions please reach out to your local Accommodation coordinator or call 1800 555 021.
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Important update regarding our accommodation services: please readBlood cancer leaves people very vulnerable to infection and viruses, including COVID-19, and the Leukaemia Foundation has long prioritised heightened infection control, even before this pandemic. As we all learn to live with COVID-19, the Leukaemia Foundation has introduced a raft of new safety measures to further protect people with blood cancer, including those staying in our accommodation centres. COVID-19 vaccines give us the best shot at stopping the virus endangering the lives of the most vulnerable in our community. They’re excellent at slowing the spread of the virus in the general population, which is vital because we know the vaccines offer less protection to many of those with blood cancer, who remain vulnerable. As part of our new safety measures, anyone 16 years and over who stays in or visits our accommodation centres, including patients and their carers and families, must show they’re fully vaccinated, unless medically exempt or undergoing emergency treatment. We’re asking all our accommodation staff and contractors to be fully vaccinated, too. We’d like to thank everyone living and working in our accommodation already vaccinated for your help safeguarding the lives of people with blood cancer. The Leukaemia Foundation will continue to do everything it possibly can to protect those we support. Visit leukaemia.org.au/covid19 to learn more about the Leukaemia Foundation’s latest information and advice about COVID-19.
I have read and understood the above
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Do you consent to sharing personal information with the Leukaemia Foundation and other appropriate health services for the purposes of assessing eligibility for accommodation support?* This field is required.
YESNO
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Is this accommodation request related to someone living with a blood cancer?* This field is required.
YESNO
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Let's start with a little about you. Are you applying as:
A person with blood cancer
Parent or guardian of someone with blood cancer
Carer of someone with blood cancer
Healthcare Professional
Leukaemia Foundation Staff Member
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Please provide us with the following contact details for yourself as the applicant:
Your name (applicant)
Your contact number (applicant)
Your email (applicant)
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Could you describe in more detail your relationship to the person with blood cancer?
Husband
Wife
Partner
Parent
Child
Family Member
Friend
Social Worker
Treating Team (Nurse/Consultant/Haematologist etc)
Welfare Worker
Care Giver
9
Leukaemia Foundation Blood Cancer Centres are independent living facilities that accommodate multiple families in close proximity. Does the patient suffer from any mental/emotional health issues which may impact their safety staying in an independent living facility where other families may be close by?
No
Yes
If YES, please provide further detail here
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Patient details:* This field is required.
First Name
Last Name
Date of birth
Yes
No
Is the patient under 18 years of age?
Female
Male
Other
Prefer not to say
Gender patient identifies as
Yes
No
Does the patient identify as Aboriginal or Torres Strait Islander?
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Patient contact details:
Contact email address
Contact phone number
Address
Suburb/Town
ACT
NSW
NT
QLD
SA
TAS
VIC
WA
State
Postcode
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Patient diagnosis and treatment information:
Blood cancer diagnosis
Sub-type (if applicable)
Year of diagnosis
Just diagnosed
In treatment
Palliative
Relapse
Unknown
Stage of disease
Which treating hospital will the patient be attending?
ACT
NSW
NT
QLD
SA
TAS
VIC
WA
In which state will the patient be undergoing treatment?
Treating Specialist's full name
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Unfortunately we do not currently have a Leukaemia Foundation accommodation facility in your area, however we may be able to offer a subsidy for commercial/external accommodation. Would you like to continue this application?
YESNO
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Is a carer available to reside with the patient at the accommodation?
YESNO
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Without a carer we are unable to offer accommodation in a Leukaemia Foundation facility, however we may be able to offer a subsidy for commercial/external accommodation. Would you like to continue this application?
YESNO
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Is the carer under 18 years of age?
YESNO
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Without a carer aged 18 or over, we are unable to offer accommodation in a Leukaemia Foundation facility, however we may be able to offer a subsidy for commercial/external accommodation. Would you like to continue this application?
YESNO
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Can you please provide us with the following details for the carer of the patient:
Carer name
Carer contact number
Carer email
Relationship to patient (E.g. Mother, father, carer, legal representative etc.)
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Is this request for a patient accessing the MoST-LLy / BCGT (Blood Cancer Genomics Trial)?
YESNO
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Why does the patient require accommodation?
Sudden diagnosis
Tests and scans
Transplant (Stem Cell/Bone Marrow)
Treatment (including clinical trial)
Other
Please select
If OTHER, please provide further detail here
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When would the patient require accommodation to commence?* This field is required.If your request is needed within the next 2 business days, please call 1800 555 021 during business hours.
Date
Day
Month
Year
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Approximately how many nights of accommodation would be required?
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Does the patient have any additional family members who require accommodation?
Yes
No
Please select
Number of additional family members
Ages of additional family members
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Does the patient, carer, or additional family member have any disabilities, impairments or mobility issues?
Yes
No
Patient
Yes
No
Carer
Yes
No
Not applicable as no additional family members
Additional family member
If YES to any of the above, please provide further detail here
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Have options for staying with friends or family been explored?
Yes - but not suitable
No friends or family in area
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Is the patient eligible for patient travel and accommodation subsidies?
Not yet applied
Have applied and eligible
Have applied and NOT eligible
Not sure
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Please see below links to patient travel and accommodation subsidies that may be available to you:

ACT

NSW

NT

QLD

SA

TAS

VIC

WA
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Could you tell us the reason you were ineligible for these subsidies?
Live less than 50km from the treatment centre
Live between 50 and 100km from the treatment centre
Undertaking a clinical trial
Receive or eligible for other support
Overseas patient
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Can you please provide additional information as to why the patient is not eligible for these subsidies and if there are exceptional circumstances as to why accommodation support is being requested?
Huge
Large
Normal
Small
Ok
Ok
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Please provide any further information relevant to your request that may be beneficial for us to know.
Huge
Large
Normal
Small
Ok
Ok
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Final step! By clicking 'I agree' below and submitting this form, you're providing consent for your details to be used by the Leukaemia Foundation to contact you about relevant blood cancer services and information. You also consent to the Leukaemia Foundation’s Terms of Use, Privacy Commitment and Privacy Notification Statement.* This field is required.
I agree
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Thank you for completing the Leukaemia Foundation’s Accommodation Application.  

Please click submit below to complete the form.
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Thank you for completing the Leukaemia Foundation’s Accommodation Application.

Please click submit below to complete the form.

Thank you for completing the Leukaemia Foundation’s Accommodation Application.  