Government Funded Client Enquiry Form

1/20. 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 1Level 2Level 3Level 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 1Level 2Level 3Level 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.


2/20. If the person needing care, already has care in place, are any of the services very short?

Yes, we have 15 minutes servicesYes, we have 30 minutes servicesYes, we have 1 hour servicesYes, we have 1.5 hour servicesNo, all 2 hours or moreNo services in place


3/20. Does the care need to start straight away?

Yes, in a fortnightNo, in a monthNo, just trying to understand how Government Funded Home Care Packages work


4/20 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:


5/20 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:


6/20. Is the person to receive the care a:

PensionerPart-PensionerSelf-Funded RetireeI don't know

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


7/20. Is the person to receive the care:

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


8/20. Does the person to receive the care hold a Gold DVA Card?

YesNoOther


9/20. What is the age of the person to receive the care?


10/20. Is the person to receive the care legally blind?

Yes, legally blind as determined by an Optometrist or OphthalmologistNo, but has poor visionNoI don't know, we have never asked an Optometrist or Ophthalmologist


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


11/20. Is the person to receive the care currently receiving FREE nursing services?

YesNo


12/20. Is the person to receive the care currently attending a low cost Dementia Day Care Centre / Social Club?

YesNo


13/20. Is the person to receive the care currently receiving low cost services through the Commonwealth Home Support Program?

YesNo


14/20. Where is the person to receive the care currently?

in hospitalin rehabilitationin a nursing home on respitein a nursing home and wanting to return to their homeliving at homestaying with an adult child


15/20. What type of home does the person to receive care live in currently?

their own homeWith you or other familyRetirement Village – Independent LivingRetirement Village – Assisted LivingNursing Home


16/20. What suburb and state does the person to receive the care live in?

Suburb

State


17/20. 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)


18/20. What is the main aim of you contacting us?


19/20. 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?


20/20. How did you first find out about Daughterly Care?