HoME+ Referral Form
Please note : Should the Client have the following conditions (Severe Dementia, Psychosomatic Issues or Schizophrenia) Please do not proceed with the application
Applicant's Full Name (As in BC/NRIC)
*
Last 4 Characters of Applicant's NRIC (e.g. 123A)
*
Applicant's Date of Birth
*
-
Month
-
Day
Year
Applicant's Age
*
Applicant's Gender
*
Male
Female
Applicant's Race
*
Chinese
Malay
Indian
Other
Languages that the Applicant Speaks (Select All)
*
English
Mandarin
Malay
Tamil
Hokkien
Cantonese
Teochew
Hakka
Other
Applicant's Contact Number (if they have no number, please enter 0)
*
Applicant's Address
*
Unit Number
Unit Number
Block Number
Road Name
Postal Code
Residential Address
*
Marital Status
*
Single
Married
Widowed
Divorce
Applicant's Type of Housing
*
HDB
Private Condo
Private Landed
Applicant's Number of Rooms
*
1 Room
2 Rooms
3 Rooms
4 Rooms
5 Rooms
Is the house that the Applicant is living in Owned or Rented?
*
Own
Rented
Type of Housing Condo / Private Housing
*
1 Bedroom
2 Bedroom
3 Bedroom
4 Bedroom
5 Bedroom
What is the Applicant's living status?
*
Living Alone
Living with Family Members
Living with Tenants
Does the Applicant have pets?
*
No Pets
Have Pets (specify what pet)
Applicant's Medical Conditions (select ALL that are applicable)
*
Diabetes
High Blood Pressure
High Cholesterol
Heart Disease
Lung Disease
Stroke
Fall/Frail/Weak
Dementia
Depression
Incontinence
Hearing Impairment
Visual Impairment
None of the above
[OPTIONAL] Are there any other Mental/Physical Conditions or Health Concerns to take note of?
[OPTIONAL] Beyond Health Conditions, are there any additional things to take note of that you would like to share with us?
Applicant's CHAS Card Colour
*
Blue ($10 per Month)
Orange ($24 per Month)
Green ($48 Per Month)
No CHAS Card ($48 Per Month)
Public Assistance Card ($10 Per Month)
Does the Applicant's Home have Wifi Installed? (Note that HoME+ Requires Wifi and will not be able to be installed without it)
*
Yes, Wifi is installed
No, but we will be installing it soon
HoME+ cannot be used without Wifi. Please ensure arrangements are made for the applicant to install Wifi, or we will not be able to proceed with the HoME+ application. Any false information on the applicant's home Wi-Fi Status will be automatically rejected
Please fill in the details of the person that we should follow up with regarding this HoME+ application.
Point of Contact's Name
*
Point of Contact's Contact Number
*
Point of Contact's Relationship to Applicant
*
Grandparent
Parent
Sibling
Cousin
Child
Social Worker
Medical Social Worker
Volunteer
Friend
Neighbour
Niece/Nephew
Grand Aunt/Uncle
Grand Niece/Nephew
Aunt/Uncle
Sister/Brother-in-law
Daughter/Son-in-law
God Daughter/Son
God Bother/Sister
Helper
Other
Does the Applicant have any Next-Of-Kin/Emergency Contacts to be contacted in case of an emergency?
*
Yes
No
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Emergency Contacts
Please list the Applicant's Emergency Contacts (or Next-Of-Kin) in order of who should be contacted first.
Name of First Next-Of-Kin (NOK) to be contacted in case of Emergency
*
First NOK's Contact Number
*
Relationship to Applicant
First NOK's Relationship to Applicant
*
Grandparent
Parent
Sibling
Cousin
Child
Social Worker
Volunteer
Friend
Neighbour
Niece/Nephew
Grand Aunt/Uncle
Grand Niece/Nephew
Aunt/Uncle
Sister/Brother-in-law
Daughter/Son-in-law
God Daughter/Son
God Bother/Sister
Helper
Other
[OPTIONAL] Name of Second Next-Of-Kin (NOK) to be contacted in case of Emergency
[OPTIONAL] Second NOK's Contact Number
[OPTIONAL] Second NOK's Relationship to Applicant
Grandparent
Parent
Sibling
Cousin
Child
Social Worker
Volunteer
Friend
Neighbour
Niece/Nephew
Grand Aunt/Uncle
Grand Niece/Nephew
Aunt/Uncle
Sister/Brother-in-law
Daughter/Son-in-law
God Daughter/Son
God Bother/Sister
Helper
Other
[OPTIONAL] Name of Third Next-Of-Kin (NOK) to be contacted in case of Emergency
[OPTIONAL] Third NOK's Contact Number
[OPTIONAL] Third NOK's Relationship to Applicant
Grandparent
Parent
Sibling
Cousin
Child
Social Worker
Volunteer
Friend
Neighbour
Niece/Nephew
Grand Aunt/Uncle
Grand Niece/Nephew
Aunt/Uncle
Sister/Brother-in-law
Daughter/Son-in-law
God Daughter/Son
God Bother/Sister
Helper
Other
Back
Next
Select the Agency / Partner that you are from
Touch Community Services
Katong CC
Mountbatten RN
Wecare
Elderaid
House of Joy
Nee Soon East
AWWA
Lions befriender
Active Global
Other Agencies
Sliver Generation Office (Pasir Ris Punggol Satelite Office)
Sliver Generation Jalan Besar Satellite Office
Sliver Generation (Jurong Satelite Office)
Sliver Generation Office (Sembawang Satelite Office)
Sliver Generation Office
Sliver Generation Ambassador
Singapore Association for Mental Health (SAMH)
Monfort Care
Fei Yue Community Services
Allkin
Thye Hua Kwan
HCA Hospice
For Elderaid Staff
Is the Applicant a Beneficiary of Elderaid?
Yes
No
Name of Elderaid Staff
Enter Name of Agency
Agencies & Partners
Name of Staff
Contact Number
Email Address
For Sliver Generation Ambassadors
Name
Email Address
Contact Number
Which Sliver Generation Office you are volunteering in
Submit
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