1. No category

Date: ____/____/ 20____
APPLICATION FOR RESIDENTIAL CARE / RESPITE
ACAT Date: ____/____/ 20____
Preferred Site ___________________________
Income and Assets Assessment: Submitted
Home Owner
Not Submitted
Partially Supported
Self Funded
The person requires a secure unit Yes
No
Fully Supported
Diagnosis of Dementia
Permanent
Date Submitted ___/____/ 20___
Respite Care Low
High
Room Preference: Single
Share
Either
NAME
ADDRESS
DATE OF BIRTH
CONTACT
PERSON
Next of Kin
1st Contact
GENERAL
PRACTITIONER
Enduring Power
of Attorney /
Enduring Power
of Guardianship
Name:
Telephone Number:
Name:
Address
Telephone Number:
Mobile Number:
Name:
Address:
Mobile:
Next of Kin
Telephone Number:
Mobile:
Name:
Address:
Telephone Number:
Mobile Number:
Fax:
Name:
Address:
Telephone Number:
MEDICARE NO
PENSION TYPE
2nd Contact
Fax:
EPoA
EPoG
Expiry Date:
Number:
Health Insurance
Company:
Membership:
INFECTION STATUS:
AMBULANCE COVER
Membership No.
ALLERGIES:
NATIONALITY:
LANGUAGE:
Is an interpreter required Yes
MARITAL STATUS:
No
SMOKER:
Yes
No
*Note: UCWPA is smoke
free
Application for Residential Care / Respite
g:\new admission forms and flowcharts\admissions application form 2014.docx
ALCOHOL INTAKE:
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