Request a volunteer visitor form

Request a volunteer visitor form

Aged Care Volunteer Visitors Scheme (ACVVS)
This form is to be completed by an Aged Care Provider, ACVVS auspice coordinator, recipient, or their representative.
Date of Referral

DayMonthYear
Date
Care Recipient

Recipients on CHSP and / or Respite Care are not elegible for our service
Please indicate relevant aged care service

Living in Residential Aged CareReceiving a Home Care PackageApproved & waitlisted for Home Care Package
Who has given consent to refer the recipient and provide information?

Recipient, Next of Kin or Power of Attorney must give consent
Name*
Relationship to recipient*
Referrer

Referrer details
Referrer Name*
Name of the person completing this form.
Relationship to recipient*
Phone number*
Email
Care Provider (If known)

Please provide details of the Aged Care Facility or Home Care Provider
Aged Care Provider
e.g. Anglicare, Southern Cross Care, ECH, ACH....
Address
Branch address
Phone number
Contact Person
e.g. Lifestyle Coordinator, Care Coordinator, Care Manager
State
Email
Care Recipient Details

Please provide details of the older person needing support
Name*

TitleFirst NameSurname
DOB*

DayMonthYear
Please enter Care recipient DOB
Gender*
Preferred Pronouns
Country of origin*
Preferred Languages*
Background eg work family culture
e.g. Electrician, used to work in a factory. Came to Australian back in early 70's. Has 2 children. Relatives live interstate.
Hobbies and Interests
Current visitors and relationships*
Suggested activities for visitor*
During lock downs (e.g. COVID 19, Gastro), illness, hospitalisation, etc. if face-to-face visits are postponed we offer other ways of communication. Please indicate what types of visit the older person would prefer to participate in.*

PhoneVideo e.g. zoom/skype/teamsLetters/postcard/emails
Special Need Group

The following information is important as it will be used to better direct the care recipient to services and is requested by the Department of Health. The information will be kept in the strictest of confidence
Please indicate which of the following groups the recipient most identifies with: *
If other please describe
Health Status:

Please include any health issues that may impact on visits such as mobility, hearing, eyesight, continence, speech, dementia and/or challenging behaviour. This information is vital to ensuring a suitable match.
Person living with cognitive impairment, including dementia*
Person living with a disability*
Person who is deaf or hard of hearing*
Person who is blind or may have limited eyesight*
Person living with mobility issues*
Person that has difficulty speaking*
Other relevant health issues
e.g. Please list any Mental Health/Significant trauma, etc
Visitor Preferences:

This information is vital to ensuring a suitable match.
Gender
Age
Please indicate if the older person has a preference e.g. 30+, 40+, 50+, or any
Language or Cultural Preferences*
e.g. Culture, Country of Origin, religious affiliation, etc
Does the recipient speaks English and would be open to consider an English-Speaking visitor*
Home Care Package Recipients Only:

Please complete the following section only if the care recipient is receiving a Home Care Package
Care Recipient Home Address
Please include Postcode
Phone number
Emergency contact person
e.g. Next of kin, family member, Home care Coordinator
Relationship
e.g. Next of kin, family member, Home care Coordinato
Phone number
Alternate phone / Email address
e.g. Next of kin, family member, Home care Coordinator
Should be Empty:

Request a volunteer visitor form

Care Recipient

Who has given consent to refer the recipient and provide information?

Referrer

Care Provider (If known)

Care Recipient Details

Special Need Group

Health Status:

Visitor Preferences:

Home Care Package Recipients Only: