Residential Care Application Form
Type of Care seeking
Respite
Permanent
Date
-
Day
-
Month
Year
Date
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
Suburb
State
Post Code
Phone Number
-
Area Code
Phone Number
Email
example@example.com
Date of Birth
*
-
Day
-
Month
Year
Date
Marital Status
Country of Birth
Languages spoken
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Pensioner:
Full pension
Part pension
No pension
Pension Type:
Please Select
Centrelink
DVA
Pension / DVA Number
Expiry Date
Medicare Card Number
Medicare Reference number
Medicare Expiry date
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Next of Kin/Preferred Contact
First Name
Last 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 Name
Last Name
GP's Phone Number
Please enter a valid phone number.
General Practice Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
GP's Email
example@example.com
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Have you or any immediate family members served?
Please Select
Yes
No
Service Type:
Are you an NDIS participant/recipient?
Please Select
Yes
No
Do you consent to a criminal history check?
Please Select
Yes
No
Do you have any disclosable criminal history of risk?
Please Select
No
Yes
Are you a smoker?
Please Select
No
Yes
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Current Influenza vaccination status?
Please Select
Yes
No
If No, please detail why:
Date of vaccination
-
Month
-
Day
Year
Date
Current COVID-19 vaccination status:
Please Select
Yes, double vaccination and booster
Yes, double vaccination only
Single vaccination
Not vaccinated
If not vaccinated, please detail why
Is there a medical exemption for vaccinations?
Please Select
Yes
No
Please attach evidence of medical exemption for vaccinations
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Please attach current evidence of immunisation status
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Who would you prefer us to contact regarding this application?
Applicant
Next of Kin
other
Please provide contact details
How did you hear about us?
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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
$750,000
$700,000
$650,000
$600,000
$550,000
$450,000
ANGLE PARK
$425,00
Government Supported
MURRAY BRIDGE
$395,000
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.
Asset Evaluation
Have you owned a house/unit/land in the last two years?
Please Select
Yes
No
Is a spouse or dependent child residing in this house/unit?
Please Select
Yes
No
Has a carer/close relative eligible for a pension or benefit resided in this house/unit for the last five years?
Please Select
Yes
No
Value of personal effects?
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.
Finance Respite Application
Do you hold a DVA card?
Please Select
Yes
No
If yes, please provide DVA card number
Have you used any respite this financial year?
Please Select
Yes
No
If yes, please specify how many days you have used
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APPLICATION
To be placed on our residential care waiting list, kindly submit this form along with a copy of your recent 'Patient Health Summary' (this can be obtained through your GP) and a copy of your 'Aged Care Client Record' or 'My Support Plan/ACAT Assessment'
or please provide us with a 'Referral Code'
Please upload: Patient Health Summary along with your 'Aged Care Client Record' or 'My Support Plan/ACAT Assessment'
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