HoME+ Referral Form (For Partners & Elderaid)

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*

MonthDayYear
Applicant's Age*
Applicant's Gender*

MaleFemale
Applicant's Race*

ChineseMalayIndianOther
Languages that the Applicant Speaks (Select All)*

EnglishMandarinMalayTamilHokkienCantoneseTeochewHakkaOther
Applicant's Contact Number (if they have no number, please enter 0)*
Applicant's Address*

Unit Number

Unit Number

Block NumberRoad Name

Postal Code
Residential Address*
Marital Status*

SingleMarriedWidowedDivorce
Applicant's Type of Housing*

HDBPrivate CondoPrivate Landed
Applicant's Number of Rooms*

1 Room2 Rooms3 Rooms4 Rooms5 Rooms
Is the house that the Applicant is living in Owned or Rented?*

OwnRented
Type of Housing Condo / Private Housing*

1 Bedroom2 Bedroom3 Bedroom4 Bedroom5 Bedroom
What is the Applicant's living status?*

Living AloneLiving with Family MembersLiving with Tenants
Does the Applicant have pets?*

No PetsHave Pets (specify what pet)
Applicant's Medical Conditions (select ALL that are applicable)*

DiabetesHigh Blood PressureHigh CholesterolHeart DiseaseLung DiseaseStrokeFall/Frail/WeakDementiaDepressionIncontinenceHearing ImpairmentVisual ImpairmentNone 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 installedNo, 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*

GrandparentParentSiblingCousinChildSocial WorkerMedical Social WorkerVolunteerFriendNeighbourNiece/NephewGrand Aunt/UncleGrand Niece/NephewAunt/UncleSister/Brother-in-lawDaughter/Son-in-lawGod Daughter/SonGod Bother/SisterHelperOther
Does the Applicant have any Next-Of-Kin/Emergency Contacts to be contacted in case of an emergency?*

YesNo

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*

GrandparentParentSiblingCousinChildSocial WorkerVolunteerFriendNeighbourNiece/NephewGrand Aunt/UncleGrand Niece/NephewAunt/UncleSister/Brother-in-lawDaughter/Son-in-lawGod Daughter/SonGod Bother/SisterHelperOther
[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

GrandparentParentSiblingCousinChildSocial WorkerVolunteerFriendNeighbourNiece/NephewGrand Aunt/UncleGrand Niece/NephewAunt/UncleSister/Brother-in-lawDaughter/Son-in-lawGod Daughter/SonGod Bother/SisterHelperOther
[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

GrandparentParentSiblingCousinChildSocial WorkerVolunteerFriendNeighbourNiece/NephewGrand Aunt/UncleGrand Niece/NephewAunt/UncleSister/Brother-in-lawDaughter/Son-in-lawGod Daughter/SonGod Bother/SisterHelperOther

Select the Agency / Partner that you are from

Touch Community ServicesKatong CCMountbatten RNWecareElderaidHouse of JoyNee Soon EastAWWALions befrienderActive GlobalOther AgenciesSliver Generation Office (Pasir Ris Punggol Satelite Office)Sliver Generation Jalan Besar Satellite OfficeSliver Generation (Jurong Satelite Office)Sliver Generation Office (Sembawang Satelite Office)Sliver Generation OfficeSliver Generation AmbassadorSingapore Association for Mental Health (SAMH)Monfort CareFei Yue Community ServicesAllkinThye Hua KwanHCA Hospice
For Elderaid Staff
Is the Applicant a Beneficiary of Elderaid?

YesNo
Name of Elderaid Staff
Enter Name of Agency
Agencies & Partners
Name of Staff
Contact Number
Email Address
For Sliver Generation Ambassadors
Name
Contact Number
Which Sliver Generation Office you are volunteering in
Should be Empty: