Questionnaire

1

Let's start by telling us who the home care is for?* This field is required.

Myself

Parent

Spouse

Someone Else

2

Great...and how old is the person who's in need of support?* This field is required.

64 years and below

65 - 79 years old

80 - 89 years old

90 years old and above

3

Got it. Now, is there currently any home care support in place?* This field is required.

Yes

No

4

...and how often is this support provided?

Once per fortnight

1-2 times per week

3 or more times per week

5

Ok...and has an assessment with My Aged Care been completed yet?

Yes

No

I don't know

7

Ok. So tell me, what's the main challenge you're wanting to solve?* This field is required.

Need more help at home

Need better quality service

Need lower fees

Something else

8

Are you approved for a Home Care Package?

Yes

No

I don't know

10

Name* This field is required.

First Name

Last Name

11

Phone number* This field is required.

12

What's your email address?

example@example.com