CLIENT APPLICATION/INTERVIEW FORM

CLIENT APPLICATION/INTERVIEW FORM
Be Uplifted Inc B1, 194 Zillmere Road, Boondall 4034

Charity Reg: CH2014 Email: info@beuplifted.org.au
Case Number
Referral Date

DDMMYYYY
PERSONAL DETAILS
Name
DOB

DayMonthYear
Age
Address
Email
example@example.com
Telephone

Area CodePhone Number
Mobile

Area CodePhone Number
Your Occupation:
Currently working:

YesNo
Relationship Status
Dependent Children Only
if yes, what ages?
Does Partner Work?
Where
Full/Part time
Partner Name
Partner Phone Number

Area CodePhone Number
Home Owned
Mortgage (Amount)
Rent (Amount)
p/w Rent Assistance
Do you qualify for Income Protection Insurance?
Do you qualify for/have Medicare?
Do you have health cover/health care fund?
Which fund?
DIAGNOSIS AND TREATMENT
Date of Diagnosis:
Treatment Centre
Treatment

(Please provide dates and information of treatment received)
• Chemotherapy
• Radiation Therapy
•Surgery
• Other
- Documented Evidence of Diagnosis
•Yes
•No
Previous assistance/support from professional services. If yes please describe the support you have received.

NoYes
Mummy's Wish
Chicks in Pink
Kym Walters
Cancer Australia
Canteen
Salvos/Lifeline
Centacare/Prescare
Referral

Please provide name and contact details if available.
• Social Worker
• Oncology Nurse
• Medical Practitioner
• Relative
Other
Type of Assistance requested and additional information you would like us to know.
AGREEMENT FORM
Case Number
Date

DDMMYYYY
I ( Full Name )
of ( Address )
agree for Be Uplifted Inc. to hold any information collected in support of my application for assistance in regard to my Breast Cancer Diagnosis and subsequent treatment. I understand that my personal information will not be shared with any third party or others not associated with Be Uplifted Inc. Management Committee. I agree that if my application is successful and the assistance offered to me is of monetary value, I will keep the amount confidential between myself and Be Uplifted Inc.

I understand and am assured that my personal information will be kept in a secure location of which only members of the Management Committee have access to. I am aware that additional supporting documentation may be requested to assist in the processing of my application.

I acknowledge that Be Uplifted Inc. reserves the right to deny request for assistance if eligibility does not meet the required criteria.

I acknowledge that my file will remain open for a period of 12 months following initial referral date and that contact will occur on initial interview (phone and face to face), and on notification of outcome of the assessment of my case. I understand that should I require further assistance after my case is closed (12 months) a further application and a new assessment will be undertaken by Be Uplifted Inc. Management Committee.

I have read and understood this agreement and further agree that the information I have given is accurate and to the best of my knowledge. I give consent for Be Uplifted Inc. to procure the necessary information to complete my request for assistance.
Client Signature

Clear
Print Name
Be Uplifted Inc. representative/s:
. Print Name
. Print Name
Be Uplifted Inc. recognises the privilege that you have given us by sharing your personal journey with Breast Cancer. It is our duty of care to act in a professional, caring and confidential manner and will endeavour to conduct ourselves accordingly.

2019 Be Uplifted Inc Client Application/ Interview Form
Should be Empty:

CLIENT APPLICATION/INTERVIEW FORM

PERSONAL DETAILS

DIAGNOSIS AND TREATMENT

Treatment

Referral

AGREEMENT FORM