Residential Care Application Form

Residential Care Application Form
Type of Care seeking

RespitePermanent
Timeframe you are looking for care?

Now1 - 4 weeks1 - 4 months+ 4 months
Date

DayMonthYear
Date
Name*

First NameLast Name
Preferred Name
Preferred Name
Address*

Street Address

Street Address Line 2

SuburbState

Post Code
Phone Number

Area CodePhone Number
Email
example@example.com
Date of Birth*

DayMonthYear
Date
Marital Status
Country of Birth
Languages spoken

Pensioner:

Full pensionPart pensionNo pension
Pension Type:
Pension / DVA Number
Expiry Date
Medicare Card Number
Medicare Reference number
Medicare Expiry date

Next of Kin/Preferred Contact

First NameLast Name
Relationship
Next of Kin/Preferred contact number
Please enter a valid phone number.
Next of Kin/Preferred contact Email
example@example.com
General Practioner

First NameLast Name
GP's Phone Number
Please enter a valid phone number.
General Practice Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
GP's Email
example@example.com

Have you or any immediate family members served?
Service Type:
Are you an NDIS participant/recipient?
Do you consent to a criminal history check?
Do you have any disclosable criminal history of risk?
Are you a smoker?

Current Influenza vaccination status?
If No, please detail why:
Date of vaccination

MonthDayYear
Date
Current COVID-19 vaccination status:
If not vaccinated, please detail why
Is there a medical exemption for vaccinations?
Please attach evidence of medical exemption for vaccinations

Cancelof
Please attach current evidence of immunisation status

Cancelof

Who would you prefer us to contact regarding this application?

ApplicantNext of Kinother
Please provide contact details
How did you hear about us?

Room Price List

Please indicate which accommodation price you are interested in, or if you expect to be eligible as Low Means. Our accommodation pricing is as follows:
MYRTLE BANK

$795,000$750,000$700,000$650,000$600,000
ANGLE PARK

$495,000Government Supported
MURRAY BRIDGE

$445,000Government Supported
In certain circumstances, the Government can assist with the cost of your accommodation. This varies depending on a resident's assets and income. Completing the Asset Evaluation below will assist us to determine whether any government assistance will be available. If you have a spouse, please list all assets; however note that when your spouse is remaining at home, the home is exempt from the assessment and only one half of the remaining assets will be considered.
Respite
Do you hold a DVA card?
If yes, please provide DVA card number
Have you used any respite this financial year?
If yes, please specify how many days you have used
FINANCE - Permanent
In certain circumstances, the Government can assist with the cost of your accommodation. This varies depending on a resident’s assets and income. Before you get started, you will need to gather some information about your financial situation. If you have a spouse or partner, you should include your combined income, assets and debts.
Do you have a partner?
Do you currently own (or are you paying off) the home you live in?
Does your partner, carer or close relation live in your home?
Asset Evaluation - What do I need to provide?

We will need the estimated figure for each of the following categories:
Your Annual Income (combine if you have a partner)
Your total financial assets (combined if you have a partner)
The current value of your family home: (not including household mortgage)
Your Superannuation and Other Assets
Your total debts or loans on any assets included above:
I believe the TOTAL value of assets included above are:
Your Superannuation and other assets
Cash at banks/building societies/credit unions including interest free accounts?
Value of Investments?
Combined Additional Assets?
Total Value of Assets?
Couples: Half of Total Value of Assets?
Not including value of home
Estimated Annual Income?
eg. income support payments, income from rental property, income from superannuation, income from businesses including farms, dividends etc.

Have you been assessed through My Aged Care for Respite/Permanent Residential Care?
APPLICATION

To be placed on our residential care waiting list, kindly submit this form along with a copy of your recent My Aged Care Support Plan, or please provide us with a 'Referral Code':
'Referral Code'
and upload your most recent 'Patient Health Summary' (this can be obtained through your GP)

Cancelof
Should be Empty:

Residential Care Application Form

Room Price List

Respite

FINANCE - Permanent

Asset Evaluation - What do I need to provide?

APPLICATION