CRT-PROGRAM-ENROLLMENT-APPLICATION

  • Community Restoration and Transitional Care Pathway Program.

    This is an enrollment application for Disability or Aged care participants eligible for short or medium term accommodation and care.

    Please have the following information with you to complete this form:

    - Medicare number

    - NDIS Participant ID

    . If you have any questions of difficulty completing it please call us 1800 403 050.

  • CRT PROGRAM

  • Community Restoration and Transitional Care Pathway Program

  • Section 1

  • Personal Details

  • NDIS participant or Aged Care participant
  • Date of Birth
     - -
  • Gender
  • Format: (00) 0000-0000.
  • Format: 0000-000-000.
  • Format: 0000-000-000.

  • Referral Details

  • Format: (00) 0000-0000.
  • Format: 0000-000-000.

  • Next of Kin Details

  • Next of Kin Status

  • Income Details

  • Community Restoration and Transitional Care Pathway Program

  • Do you receive Income?
  • If yes, what type of Income?
  • Do you receive Centerlink rental allowance?
  • Are you an NDIA participant?
  • If NO, are you an eligible NDIA participant?
  • Aged Care funding
  • If you don't have Aged Care Funding are you eligible?

  • Section 2

  • NDIS Support Plan

  • Are you currently receiving NDIA Funding Support

  • If YES, please mention what type of funding support you are receiving from each category below?

  • Core Support
  • Capital Support
  • Capacity Building
  • NDIA Fund Management

  • Accommodation Status

  • At present where do you reside?

  • Section 3

  • Activities of Daily Living Support - ADLS

  • Please indicate the following level of support Required

  • Community Transport / Taxi voucher
  • Personal Care Support
  • Domestic Support
  • Shopping Support
  • Medication Management
  • Transport
  • Mobility Support
  • Social and Community Participation
  • Supported Employment
  • Medical & Specialists Appointment
  • Meal Preparation
  • Feeding Support
  • Grooming Support
  • Communication
  • Bed to Chair Transfers
  • Bed Care
  • Bowel Management
  • Incontinence Management
  • Financial Management
  • Lifestyle Day to Day Decisions

  • Section 4

  • Medial Nursing and Allied Health (MDT) Support

  • Type of Care Support
  • High Intensity Care Support Needs
  • If Urinary Catheter Care required please specify

  • Section 5

  • Assisted Technology & Consumables

  • Participants mobility status
  • If Non Ambulant what Mobility Aid are you using
  • Monkey Bar
  • Sliding Table
  • Bedside Table
  • Electric Height Adjustment Table
  • Automatic Door Opening
  • Respiratory Equipments
  • Telehealth Device
  • Self Dispensing Medication Device
  • Special Gown
  • Personal Protective Equipment
  • Communication Devices
  • Telehealth System
  • Urgent / Vital Call System
  • Software Application Assistance Lifestyle Capacity Building
  • Bedai Toilet Assistance System
  • Bed Care
  • Bowel Management
  • Incontinence Management
  • Skill Development Education Program
  • Air Condition

  • Section 6

  • Lifestyle Choices & Preferences

  • Location Specific

  • Do you need Interpreter
  • English Language
  • Are you Aboriginal and Torres Strait Islander
  • Staff Care to Participant Ratio

  • Participants Consent Obtained

  • Type a question

  • Attachment

  • 1. NDIA PLAN
  • 1. Clinical Care Plan
  • 3. Hospital Discharge Report
  • Aged Care Package Support Plan
  • Should be Empty: