Additional Services Request Form-0001B

ADDITIONAL SERVICES REQUEST (Form-0001B)
Resident's Details
Name*

First NameLast Name
Date

DayMonthYear
Date
Skymac can offer you a range of services outside of what is included in your fortnightly rent/board.

These services are listed below, and it is important to note that they are not included in your board and lodging (rent). If you would like Skymac to provide you with any of these additional services, you will need to let us know by completing the following checklist.

You need to indicate how you will be paying for these services and we can provide you with a price list of our services to help you make your decision.
SERVICES

Please indicate below the services you require and payment method, or select not required:

	Public Trust	NDIS Plan	Invoiced	Not Required
Assistance with Medication (FORM-0044)
Personal Care Assistance (FORM-0045)
Financial & Administrative Assistance (FORM-0046)
Community Access Supports (FORM-0047)
Assistance with BGL Monitoring (FORM-0067)
Assistance with Tobacco Management (FORM-0068)
Assistance with Mealtime Management (FORM-0072)

By signing below, you acknowledge that the services listed above are not included on your R18 rooming agreement and are not included in the rent you pay.

You also agree to pay for your above chosen services as you have indicated. You also acknowledge Skymac’s duty of care and agree to be bound by the house rules provided with your R18, and that you understand failure to do this may result in your request being denied.

You also understand that you can amend or terminate this request at any time and seek the assistance of an external service provider if you wish.
Signature of Resident

*Or signature of person acting on authority under Guardianship Administration Act 2000 or Powers of Attorney Act 1998 for the person named above, OR an Informal Decision Maker (must have an Informal Decision Maker Details Form-0071 signed) for the person named above.
Name*

First NameLast Name
Signature*

Clear
Date*

DayMonthYear
Date
In the presence of (Witness)
Name*

First NameLast Name
Signature*

Clear
Date*

DayMonthYear
Date
Should be Empty:

ADDITIONAL SERVICES REQUEST (Form-0001B)