Private Paying Client Enquiry Form

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

    Yes, ideally this weekYes, within a fortnightNo, within a monthNo, 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 privatelyThe Government will be paying via my Home Care PackageMy Home Care Package and I will be payingWorkers Compensation will be payingInsurance Company will be payingOther (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 blindNo, but has poor visionNoI don't know


    5/9. 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


    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?