Preliminary Information and Safety Form
This Questionnaire is to be Filled by the person receiving Services or their Representative. In the interest of providing you the best service we ask that you to answer each question honestly. Your answers remain confidential to the Service Provider and or workers involved directly with your Service.This Questionnaire is a pre service check to make sure we understand any risks or personal requests which are related to your service.
Please tell us the name of the Person to Receive Service
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First Name
Last Name
Date of Birth
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-
Day
-
Month
Year
Date
Please give the phone number of the person to receive Services
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Please add your Mobile or Landline Here
Please give the email for your login and information to be sent to
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Please give the address of Person to receive Care
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Street Number
Street Name
Suburb
State
Postcode
When are you requesting your Service Commence?
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Day
-
Month
Year
Date
I am looking for the following Services
HomeCare and Community Support
In home Nursing
Health Assessment and Advice (eg. continence, post surgical, chronic illness)
Coordination of Services
Assistance with Funding applications and Reviews
Transport
Cleaning
Other
Please give a brief description of how you would like us to help you (eg daily personal care, daily wound care etc)
Please details about accessing your place of Service
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Independent Home
Apartment
Townhouse
Villa
Shared Living
Independant Living
Level dwelling
More than one level
Lift access
Stair Access
Onsite Parking
Street Parking
No Parking
Remote dwelling off Street
Difficult access or more information required
Difficulties with mobile phone reception
Difficulties with internet reception
Other
Please give further information about accessing your place of service
Please give information about the environment where service is to be provided
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There are no physical or environmental risks known
Poor Lighting
Uneven or hazardous floors
Cluttered environments
Pets on site
Allergens, asbestos, pollution
Water disruptions
Electrical disruptions
Pests
Mould and Spores
Damaged or perished areas or equipment
High or Low temperatures
Poor ventilation
Frequent flooding and water damages
There is heavy lifting or manual handling related to my service
Other
Please provide any extra information about any environmental hazards which may complicate your service
Please Give information about Personal Safety related to your service. These questions include the recipient of care, family and any other persons who may be present in your home.
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There are no known threats for staff attending services
There are persons living or frequenting who have a criminal record
There are persons living or frequenting who have substance abuse
There are persons living or frequenting who have unstable mental health conditions
There are persons living or frequenting who a history of violent or threatening behaviours
The Carer is suffering from Stress which results in aggression toward others
There are firearms present
There are weapons present
There are illegal substances present
There are explosive or unstable chemicals present
Other
Please provide any extra information about personal safety risks which may complicate your services. We may contact you by phone about this information.
Please Give Information about Infection Control Hazards related to your Service
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I have no known complications regarding cleaning, chemicals or infection control practices
I have a condition related to immunocompromise
I have a condition where I am unable to be vaccinated for COVID and or influenza
I have had 2 COVID Vaccinations
I have had more than 2 COVID Vaccinations
I have yearly influenza Vaccinations
I have regular pneumonia vaccinations
I have regular acquired respiratory infections or a respiratory condition
I have reactions related to cleaning chemicals, substances or environments
I have a skin condition or regular skin breaks
I have a known resistant infection (eg MRSA, VRE, ESBL)
I have had a previous resistant infection
Other
Please give and extra information about any concerns or conditions which effect Infection Control which may complicate your service
Please tell us if there are special requirementsfor your care and visits
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I have no known special requirements for care
Interpreter
Easy Read
Language or Other Communication
Gender Condition
Diversity
Religious Conditions
Indigenous Conditions
Adversities
Behavioural Difficulties
Focal Difficulties
Mental Health
Cognitive alterations
Other
Want to tell us more? Please tell us about any other circumstance or information you would like us to know.
Would you like to include an Advocate or Representative?
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YES
NO
Please tell us your Advocate or Representative's Name
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Please tell us your Advocate or Representative's Phone Number
Please enter a mobile or landline number
Please tell us your representative's Email Address
Please indicate the funding type
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HCP (Home Care Package)
NDIS (National Disability Insurance Scheme)
Private Health Funding
Workers Compensation
Self-Funded
Other
Please fill your My Aged Care Number
*
Please Enter you NDIS number
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NDIS Funding Management
Please Select
NDIA
Self Managed
Plan Managed
Please give the name of your private health fund
*
Please Give your Private Health Fund Identifier
*
Is there other information you would like to tell us about your Funding?
If you have special conditions or require more financial consideration please tell us here
Please give the name of your Billing Recipient
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This should be where we send your invoices
Please Give the Phone Details for Billing Recipient
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Please enter the area code and land line, or mobile number
Please give the email address for your Billing Recipient
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I agree that all information in this questionnaire is true and correct and understand that Services may be withheld if information was intentionally misrepresented.
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I Agree
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