Private Paying Client Enquiry Form

1/9. Does the care need to start straight away?

 Yes, ideally this week Yes, within a fortnight No, within a month No, just researching for the future


2/9. Assuming you choose Daughterly Care to provide the care, will you be paying privately or by a Government Funded Home Care Package?

 I will be paying privately The Government will be paying via my Home Care Package My Home Care Package and I will be paying Workers Compensation will be paying Insurance Company will be paying Other (please specify below)


3/9. What is the age of the person to receive the care?


4/9. Is the person to receive the care legally blind?

 Yes, legally blind No, but has poor vision No I don't know


5/9. 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


6/9. What suburb and state does the person to receive the care live in:

Suburb

State


7/9. 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*


8/9. What is the main aim of you contacting us?


9/9. How did you find out about Daughterly Care?