• CLIENT INTAKE / ASSESSMENT PLAN

    CLIENT INTAKE / ASSESSMENT PLAN

    NB. all required* fields need to be completed or the submit button won't work.
  • This form was completed on behalf of or by the:*

  • This section helps determine your eligibility for a government-funded meal subsidy. If completing this form for someone else, answer from their perspective.

  • Are you registered with one of the following*
  • What level was your Support at Home Package (SAH) assessed at*
  • Is your NDIS one of the following?*
  • Date of birth*
     / /
    2 digit day, 2 digit month, 4 digit year
  • Do you require language assistance?**
  • Do you require someone to speak on your behalf?*
  • Gender*

  • Contact 1 (family member, friend, neighbour, guardian, power of attorney etc.)

  • Contact 2 (family member, friend, neighbour, guardian, power of attorney etc.)

  • Do you give permission for one or both of your contacts to speak on your behalf if we can't contact you?**

  • Medical Provider

  • Living Arrangements & Government Benefits

  • Have you recently lost weight without trying?*
  • Do you have any health issues that impacts your day-to-day living?*
  • Do you require a walking aid?*
  • What is your main goal/reason for signing up with Meals on Wheels? (You can select more than one option)*
  • Is your requirement for Meals on Wheels short term or long term?*
  • Do you have any food allergies?*
  • Do you have access to any of the following to heat your meal?**
  • Meal texture required**
  • What days of the week would you like to receive meals*
  • Which courses are you interested in receiving?*
  • Are there any dogs on your property?*
  • If there are any dogs on your property can they be secured?*
  • Are there any firearms at your property?*
  • If there are firearms on your property, are they locked away in an appropriate safe?*
  • Are there any gates at your property that require opening?*
  • Invoicing preference**
  • Invoice delivery**
  • Payment method**
  • 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?*
  • Have you been informed of your aged care rights? If you are over the age of 65, please read the following 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.*
  • If you're 65 or older (50 for Aboriginal or Torres Strait Islander people), have you been informed of your aged care rights?*
  • If you have been informed of your aged care rights, was it through one of the following*
  • 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.*
  • Would you like one of our friendly staff members to contact you?*
  • We need at least 7 days’ notice to start meal deliveries — what day would you like your first meal delivered?
     - -
    2 digit month, 2 digit day, 4 digit year
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