Government Funded Client Enquiry Form

1/17. What best describes where you are up to regarding your Government Subsidised Home Care Package?

 I'm Self-funded. Would I be eligible for a Government Subsidised Home Care Package? I haven't applied for a Home Care Package. I don't understand Home Care Packages and I need someone to help explain them to me. I have been assessed by the Aged Care Assessment Team (ACAT) and have been "approved" a Home Care Package.

Hint: "Approved" means you are assessed as eligible to receive a package by ACAT and now you are on the National Queue waiting for the Government Funding to come through i.e. to be assigned. Click here to find out, what the difference between "Approved" and "Assigned" is.

What level have you been "approved" for:

 Level 1 Level 2 Level 3 Level 4

How long ago were you approved? (This is also the same answer as how long ago were you assessed by ACAT)

 I have been "assigned" a Home Care Package.

Hint: "Assigned" means My Aged Care has written to you and given you a date that you must choose an Approved Provider by. Click here to find out, what the difference between "Assigned" and "Approved" is.

What level were you "assigned"?

 Level 1 Level 2 Level 3 Level 4

What is the deadline date to choose your Approved Provider in your My Aged Care letter?

Tip: If time is close to your deadline, it is imperative you give us your telephone number and email address below.

2/17. If the person needing care, already has care in place, are any of the services very short?

 Yes, we have 15 minutes services Yes, we have 30 minutes services Yes, we have 1 hour services Yes, we have 1.5 hour services No, all 2 hours or more No services in place

3/17. Does the care need to start straight away?

 Yes, in a fortnight No, in a month No, just trying to understand how Government Funded Home Care Packages work

4/17 If the person needing care, already has care in place and it is being paid for by the Government, which Approved Provider is currently providing the care?

Tip: You will be receiving a monthly statement from them.

Your Current Approved Provider's Name:

5/17 If the person needing care, already has care in place and you are paying for it privately, which company is providing the care?

Your Current Private Care Provider's Name:

6/17. Is the person to receive the care a:

 Pensioner Part-Pensioner Self-Funded Retiree I don't know

Tip: We don't care what your answer is, it just helps us give you the right information.

7/17. Is the person to receive the care:

 Part of a couple living together Part of a couple living apart separated by poor health (e.g. one is in a nursing home) Single Widow / Widower

8/17. Does the person to receive the care identify as any of these groups who get priority access to Government Funded In Home Care?:

 Aboriginal and Torres Strait Islander communities Non-English speaking (culturally and linguistically diverse) background Lives in rural or remote areas Financially or socially disadvantaged War veteran, including the spouse, widow or widower of a veteran Homeless, or at risk of becoming homeless Parent who was separated from their child(ren) by forced adoption or removal A Care Leaver i.e. was in an orphanage or Forster home under the age of 18 Identifies with the Lesbian, Gay, Bisexual, Transgender and Intersex (LGBTI) community None of the above I don't know

Congratulations, you're half way there! Keep going, these questions help us give valuable, relevant and correct information

9/17. What is the age of the person to receive the care?

10/17. Is the person to receive the care legally blind?

 Yes, legally blind as determined by an Ophthalmologist No, but has poor vision No I don't know, we have never asked an Ophthalmologist

11/17. Where is the person to receive the care currently?

 in hospital in rehabilitation in a nursing home on respite in a nursing home and wanting to return to their home living at home staying with an adult child

12/17. What type of home does the person to receive care live in currently?

 their own home With you or other family Retirement Village – Independent Living Retirement Village – Assisted Living Nursing Home

13/17. What suburb and state does the person to receive the care live in?



14/17. Enquirer's Name and Contact details:

*Mandatory fields

Your Full Name*

Your relationship to the Elder / Care Recipient*

Your Email* (a copy of this form will be emailed to you)

Telephone Number* (for us to call you)

15/17. What is the main aim of you contacting us?

16/17. Is there anything else you think we need to know to best help you e.g. what is the goal of your home care? Do you have specific questions we may be able to help you with?

17/17. How did you first find out about Daughterly Care?