Government Funded Client who already has a Home Care Package Enquiry Form

1/19. How do you feel about your Current Approved Provider?

 We are satisfied with our Current Approved Provider. We are NOT entirely satisfied with our Current Approved Provider We are very disatisfied with our Current Approved Provider and researching the possibility of moving We have already decided that we are leaving our Current Approved Provider


2/19. Are any of your current 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 services are 2 hours or more


3/19. Does the care need to start straight away?

 Yes, ideally next week and I can pay privately until my Government funding transfers across to Daughterly Care No, just researching at this stage


4/19. Which Approved Provider is currently administering your Home Care Package? Tip: You will be receiving a monthly statement from them.

Your Current Approved Provider's Name:


5/19. Which company is currently providing your CARE services? (It might be the same as the previous question or it could be a different company)

Your care is provided by:


6/19. Have you been receiving a Home Care Package prior to 30 June 2014?

 Yes No


7/19. What level of Home Care Package are you currently actually receiving? (This might be less than what you are "approved" to receive):

 Level 1 Basic Care Level 2 Low Care Level 3 Medium Care Level 4 High Care I don't know


8/19. What level ACAT Assessment have you got? (We're trying to determine if you are receiving a Home Care Package that is equal to your Aged Care Assessment

You might have an assessment under the old assessment criteria ie:

 Low Care Level 1/ Level 2 High Care Level 3 / Level 4

Or you might have an assessment under the new system where ACAT assigns the actual level and priority:

 Low Care Level 1 Low Care Level 2 High Care Level 3 High Care Level 4 I don't know


9/19. If you are receiving care that is level 3 or lower, how long ago was your ACAT Assessment done?

Month

Year

 I don't know


10/19. Is the person to receive the care a:

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


Congratulations, you're half way there!


11/19. 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


12/19. 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


13/19. 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


14/19. What suburb and state does the person to receive the care live in:

Suburb

State


15/19. 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*


16/19. What is the main aim of you contacting us?


17/19. Is there anything else you think we need to know to best help you e.g. What is the goal of your home care? Or why are you dissatisfied?


18/19. What days and times do you currently receive services? (Answer only, if you are considering Daughterly Care to provide Caregivers for those services)

Day

Time from

Time to

 Monday
 Tuesday
 Wednesday
 Thursday
 Friday
 Saturday
 Sunday


19/19. How did you find out about Daughterly Care?