Private Paying Client to Start Services Form

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

 Yes, ideally this week No, within a fortnight No, within a month


2/9. You have decided to use Daughterly Care to provide privately paid care

 I will be paying privately, I don't plan to apply for a Government Subsidised Home Care Package I will be paying privately until my Government funding starts (assigned) I will be paying privately and from a Government Subsidised Home Care Package


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. Ideally, what days and times would you like services and briefly what is our role?



8/9. 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*


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