ACVVS recipient referral form

Recipient referral form

Request for a companion to visit
Please use this form to ask for an Aged Care Volunteer Visitor Scheme (ACVVS) volunteer to visit yourself or someone else regularly.

Responses in this form help us understand the situation of the person who would benefit from extra company and help us find a volunteer visitor who's a great match.

The service is free for the recipient, funded by the Australian Government.

If you have a question about completing this form, please email acvvs@lifelinewa.org.au, phone the Coordinator on 0425 661 816, 9261 4423 or phone Lifeline WA reception on 9261 4444.
Name of person to receive visits (recipient)*

Given nameFamily name
Date of recipient's birth*

DayMonthYear
Date
Does the recipient live in an aged care facility?*

YesNo
Aged care facility name
Aged care facility phone number
Is the recipient receiving/approved for a home care package?*

YesNo
Home care package provider name
Home care package provider number
To be eligible to be a recipient in the ACVVS, one of the following must apply. They live:
- in a residential aged care home
- at home and are receiving/approved for a Home Care Package.
If neither of the above apply to your situation, please don't complete this form but call Lifeline WA's ACVVS Coordinator on 0425 661 816, 9261 4423 or Lifeline WA reception on 9261 4444.
Is it the recipient who is filling out this form?*

Yes, I'm requesting a visitor for myselfNo, I'm referring someone else to receive a visitor
Referrer's name
Referrer's relationship to recipient
Referrer's phone number
Referrer's email
example@example.com
Is it OK for the ACVVS Coordinator to contact the recipient directly?

Yes, the ACVVS Coordinator can contact the recipient directlyNo, please contact me firstNo, please contact the person below first
Their name is Given name Family name and their phone number is contact number* .
Recipient information
Recipient's home address where visit will take place*
Recipient's phone number (if applicable)
Recipient's email (if applicable)
example@example.com
Recipient's emergency contact - name*
Recipient's emergency contact - relationship*
Recipient's emergency contact - contact number*
Country of birth*

AustraliaOther
Preferred language*

EnglishOther
Gender identity and preferred pronouns
For example, male, female, non-binary, he/him, she/her, they/them, other
Does the recipient identify as being part of any of the following groups, as specified under the Aged Care Act 1997? Tick all that apply.

From Aboriginal and Torres Strait Islander communitiesFrom culturally and linguistically diverse backgroundFinancially or socially disadvantagedVeteransLesbian, gay, bisexual, transgender and intersexCare leavers - people separated from their children by forced adoption or removalPeople who are homeless, or at risk of becoming homelessNo, none of the above apply
Reason for requesting a visitor
For example, recipient's family moved interstate and can't visit regularly
Current visitors
For example, son visits once a week
Background – family/culture/work history
For example, migrated to Australia from Serbia in 1996, was a teacher, two brothers in Perth
Hobbies and interests
For example, music, watching AFL, walking, crochet, playing Scrabble
Recipient's health

Please indicate, and give brief notes on, each of the below that apply to the recipient.
Cognitive impairment/dementia

YesNo
Details of cognitive impairment/dementia
Deaf/hearing impairment

YesNo
Details of hearing impairment
Speech challenges

YesNo
Details of speech challenges
Vision impairment

YesNo
Details of vision impairment
Diagnosed mental illness/mental health concern/significant trauma

YesNo
Details of any mental health illness/concern
Mobility challenges

YesNo
Details of mobility challenges
Continence challenges

YesNo
Details of continence challenges
Other disability

YesNo
Details of other disability
Any other behaviour/s
Can the recipient go on outings without personal care support?*

YesNo
What support does the recipient need for an outing?
For example, wheelchair, taxi, walker
Any other relevant health information
What else do we need to know so the community visitor can meet their duty of care?
Do you have preferences about the visitor?
Their gender

AnyMaleFemaleNon-binary
Their age

Any18–35 years of age36–45 years of age46 years of age and over
Do you have any other preferences for the visitor?
For example, Aboriginal or Torres Strait Islander peoples, culturally and linguistically diverse, LGBTQI+, religion
What activities will the recipient and visitor likely do together?
Any other comments
How did you hear about us?*
If you would prefer to complete a hard copy of this form, please contact acvvs@lifelinewa.org.au
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Recipient referral form

Recipient information

Recipient's health

Do you have preferences about the visitor?