CLIENT INTAKE / ASSESSMENT PLAN
NB. all required fields need to be completed or the submit button won't work.
Participant name
*
First Name and preferred name
Last Name
This form was completed on behalf of or by the:
Participant
Primary/secondary contact
HCP provider
Other
Completing this section will help us ascertain if you are eligible for a government-funded subsidy on your meals.
Are you registered with one of the following
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My Aged Care (MAC)
Home Care Package (HCP)
National Disability Insurance Scheme (NDIS)
Transitional Care Package (TCP)
Home and Community Care (HACC)
None of the above
My Aged Care #
*
Registering with My Aged Care will give you a discount on your meals.
My Aged Care Referral code
*
If you don't have a specific meals referral code, you can contact MAC after you have completed this form and ask for one to Meals on Wheels.
What level was your Home Care Package (HCP) assessed at
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Yes (level 1)
Yes (level 2)
Yes (level 3)
Yes (level 4)
HCP Provider and Case Manager name
*
Is your NDIS one of the following?
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Self managed
Plan managed
NDIA managed *NB, we are not a registered provider, you will be charged full cost*
NDIS Number
*
Provider contact details
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Commonwealth Home Support Program (CHSP)
My Aged Care (MAC)
Meal Prices (Payable by the client). Soup - $2.70. Main -$9.95. Dessert - $3.70. Yoghurt - $2.00. Snack Dessert - $1.50 (custard). Snack Dessert -$1.30 (jelly). Gluten Free Dessert - $5.00. Sandwich - $6.00.
*
I understand that these prices will apply to the items I select from the menu.
Support at Home (SAH)
Meal Prices (Payable by the client). Soup - $0.95. Main - $5.20. Dessert - $1.70. Yoghurt - $0.75 Snack Dessert (custard) - $0.75. Snack Dessert (jelly) -$0.50. Gluten Free Dessert - $2.00. Sandwich - $2.65.
*
I understand that these prices will apply to the items I select from the menu.
National Disability Insurance Scheme (NDIS)
Meal Prices (Payable by the client). Soup - $0.95. Main - $5.20. Dessert - $1.70. Yoghurt - $0.75. Snack Dessert (custard) - $0.75. Snack Dessert (jelly) -$0.50. Gluten Free Dessert - $2.00. Sandwich - $2.65.
*
I understand that these prices will apply to the items I select from the menu.
Transitional Care Packages (TCP)
Meal Prices (Payable by the client). Soup - $0.95. Main - $5.20. Dessert - $1.70. Yoghurt - $0.75. Snack Dessert (custard) - $0.75. Snack Dessert (jelly) -$0.50. Gluten Free Dessert - $2.00. Sandwich - $2.65.
*
I understand that these prices will apply to the items I select from the menu.
Home and Community Care (HACC)
Meal Prices (Payable by the client). Soup - $2.70. Main -$9.95. Dessert - $3.70. Yoghurt - $2.00. Snack Dessert - $1.50 (custard). Snack Dessert -$1.30 (jelly). Gluten Free Dessert - $5.00. Sandwich - $6.00.
*
I understand that these prices will apply to the items I select from the menu.
Full Cost Recovery (FCR) – No Government Subsidy.
Meal Prices – per course (without subsidy): Soup - $5.30. Main - $13.50. Dessert - $6.90. Yoghurt - $3.00. Snack Dessert (custard) - $3.00. Snack Dessert (jelly) - $2.50. Gluten Free Dessert - $7.50. Sandwich - $9.00.
*
I understand that these prices will apply to the items I select from the menu.
Client Address
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Client contact number
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Mobile
landline
Email
Postal address if different from above
Date of birth
*
/
Day
/
Month
Year
Country of birth
Spoken language
Aboriginal/Torres Strait Islander:
*
Please select
Both Aboriginal/Torres Strait Islander
Aboriginal
Torres Strait Islander
None of the above
How did you hear about us?
Do you require language assistance?*
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Yes
No
Do you require someone to speak on your behalf?*
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Yes
No
Unsure
Gender
*
Male
Female
Prefer not to say
Prefer to self-describe
Contact 1 (family member, friend, neighbour, guardian, power of attorney etc.)
Name of contact 1
*
First Name
Last Name
Relationship*
*
Postcode
*
Preferred contact number
*
Email
*
Contact 2 (family member, friend, neighbour, guardian, power of attorney etc.)
Name of contact 1
*
First Name
Last Name
Relationship*
*
Postcode
*
Preferred contact number
*
Email
*
Do you give permission for one or both of your contacts to speak on your behalf if we can't contact you?*
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Yes (contact 1)
Yes (contact 2)
No (contact 1)
No (contact 2)
Contacting your emergency contacts.
Medical Provider
GP's name
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Name of medical centre
*
Living Arrangements & Government Benefits
Living arrangements*
*
Please select
Single person (living alone)
Single person (living with dependent)
Couple
Couple (living with dependent)
Group (related adults)
Group (unrelated adults)
Homeless (no household)
Household Composition*
*
Please select
Boarding house
Crisis, emergency or transition
Independent living unit
Indigenous community/settlement
Institutional setting (residential aged care/hospital)
Private residence (client or family owned)
Private rental
Public rental
Public shelter
Supported accommodation
DVA Card
*
Please select
DVA gold card
DVA White card
Other DVA card
No DVA card
DVA card number
Govt Pension/Benefits
Please select
Aged Pension
Veteran Affairs pension
Disability Support Pension
Carer Payment
Unemployment Related Benefits
Other Government Pension or Benefit
Government Pension or Benefit
Do you have a carer?*
*
Please select
Has a carer
Does not have a carer
Has a family member offering support
Carer living arrangements
Please select
Co-resident carer
Non-resident carer
Carer Relationship
Please select
Spouse/partner
Parent
Son or daughter
Other relative
Friend or neighbour
Carer Primary Spoken Language
Please list any third-party services you receive.
E.g., cleaning, gardening, domestic assistance or personal assistance
Medicare#
Medicare expiry
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Day
-
Month
Year
Date
Have you recently lost weight without trying?*
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Yes
No
Approximately how many kilograms do you think you have lost and why?
Do you have any health issues that impacts your day-to-day living?*
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Arthritis
Chewing or swallowing food
Dementia
Diabetes type 1
Diabetes type 2
Hearing impairment
Intellectual learning
Memory loss
Mental health
Mobility issues
Recent weight loss
Sensory/speech
Vision impairment
None
Other
Do you require a walking aid?*
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Walking stick
Walking frame
Wheelie walker
Wheel chair
Crutches
Walking cane
None of the above
Please list any other health conditions here
What is your main goal/reason for signing up with Meals on Wheels? (You can select more than one option)
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Improve my nutritional intake.
Improve diversity in my diet.
Social wellbeing/contact.
Alleviate mobility issues.
Recover from illness or injury.
To liberate myself from the kitchen (I don’t enjoy cooking).
Save time.
Other
reason for signing up with Meals on Wheels
Is your requirement for Meals on Wheels short term or long term?
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0 – 6 weeks
6 weeks to 6 months
6 months – 12 months
More than 12 months
Unsure
Please list any food allergies i.e., gluten, nuts…
Do you have any dietary requirements? i.e., vegetarian, diabetic, salt reduced& or cultural requirements.
Do you have access to any of the following to heat your meal?*
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Air fryer
Microwave
Oven
Stove
Other
Meal texture required*
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Normal
Soft
Pureed
Moist
Minced
Cut into bite size pieces
What days of the week would you like to receive meals
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Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Unsure
Which courses are you interested in receiving?
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Soup
Main
Sweet
Salad
Sandwiches
Unsure
Are there any dogs on your property?
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Yes
No
If there are any dogs on your property can they be secured?
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Yes
No
Are there any firearms at your property?
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Yes
No
If there are firearms on your property, are they locked away in an appropriate safe?
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Yes
No
Are there any issues with the driveway to your home or should we park on the road?
Are there any issues with accessing the main door, if so, is there an alternate door to use?
Are there any gates at your property that require opening?
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Yes
No
Summarise delivery instructions/ directions or access issues for the driver. Knock/ring doorbell?
Invoicing preference*
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Mid-month
End of month
Invoice delivery*
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Emailed
Delivered with your meal
Payment method*
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Credit card
Cheque
Deposit
Centrepay
Other
Do you consent to the sharing of your personal information with other service providers ONLY where required and the My Aged Care Portal ONLY if required?
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Yes
No
Have you been informed of your aged care rights? If you are over the age of 65, please read the following attached document. The new Aged Care Act includes a Statement of Rights, outlining the rights that older people have when accessing aged care services. The rights outlined in the Act help to ensure that older people and their needs are at the centre of the new aged care system. The Statement of Rights includes the right to: independence, autonomy, empowerment and freedom of choice, equitable access, quality and safe funded aged care services, respect for privacy and information, person-centred communication and ability to raise issues without reprisal, advocates, significant persons and social connections. Meals on Wheels must ensure that our actions are consistent with the Statement of Rights.
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If you're 65 or older (50 for Aboriginal or Torres Strait Islander people), have you been informed of your aged care rights?
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Yes
No
This is the first time I have seen the Statement of Rights
If you have been informed of your aged care rights, was it through one of the following
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Meals on Wheels
My Aged Care (MAC)
Home Care Package Provider (HCP)
National Disability Insurance Scheme (NDIS)
Transitional Care Package (TCP)
Home and Community Care (HACC)
Other
After reviewing the above Statement of Rights, do you understand that Meals on Wheels must ensure that our actions are consistent with the Statement of Rights.
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Yes
No
Would you like one of our friendly staff members to contact you?
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To go through the Statement of Rights out to you.
To answer any questions you may have.
No, I understand my rights.
We need at least 7 days’ notice to start meal deliveries — what day would you like your first meal delivered?
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Month
-
Day
Year
Date
Client Signature
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Submit
Submit
OFFICE USE ONLY
Info pack given
CRM updated/uploaded
Branch updated
CSO checked
Finance advised
Should be Empty: