My Aged Care My Aged Came Package Intake Form Please complete the form below and our team will be in touch with you shortly. Referrer Details Referrer: first name Referrer: Surname Email address Phone number Relationship to participant -- Select an answer --Case managerFamily memberLegal guardianParticipantPrimary carerSupport coordinatorOther If other, please describe Participant Details Participants Package Level Participant: first name Participant: Surname Participant: Preferred first name Email address Phone number Date of Birth Residential address Suburb/Town State Postcode Preferred method of communication -- Select an answer --EmailPostSMSPhone Attach Current Health Summary Plan Details Is your plan Self managedPackage Management provider Self Managed Provider About The Participant Marital status -- Select an answer --SingleIn a relationshipMarriedWidowedDivorcedSeparatedOther Participant living situation -- Select an answer --Own home/ living aloneOwn home/ living with familyLiving in supported accommodationHomelessTemporary (living with friends, family or other accom)At risk (e.g. evictions, behind in rent, family violence)Other Is the participant of aboriginal or torres strait islander descent? -- Select an answer --YesNoUnknown Does the participant have a current behavioural support plan? -- Select an answer --YesNo If other, please describe Does the participant have a current behavioural support plan? If yes, please attach the behavioural support plan Cognition details -- Select an answer --Very GoodOwnFairPoor Languages spoken EnglishSpanishHindiArabicPortugueseBengaliRussianJapanesePunjabiOther Communication -- Select an answer --VerbalNon verbalAidsOther Hearing impaired interpreter required? -- Select an answer --YesNo Language Interpreter required? -- Select an answer --YesNo If other, which languages? Is the participant of culturally and linguistically diverse background? -- Select an answer --YesNo Personal care - requires assistance with Shower/BathToiletingGroomingDressingOther Mobility IndependentAssistWalking StickWalking FrameManual HoistShower ChairWheelchairL FrameCeiling HoistOther If other, please describe Formal diagnosis - primary Formal diagnosis - secondary Other relevant information about the participant Do you have any legal issues that may affect services? -- Select an answer --YesNo (E.G. APPREHENDED VIOLENCE ORDER AVO) Shifts Preferred start date Preferred Shifts days and times Monday - AMMonday - PMMonday - SleepoverMonday - Active NightsTuesday - AMTuesday - PMTuesday - SleepoverTuesday - Active NightsWednesday - AMWednesday - PMWednesday - SleepoverWednesday - Active NightsThursday - AMThursday - PMThursday - SleepoverThursday - Active NightsFriday - AMFriday - PMFriday - SleepoverFriday - Active NightsSaturday - AMSaturday - PMSaturday - SleepoverSaturday - Active NightsSunday - AMSunday - PMSunday - SleepoverSunday - Active Nights How did you hear about Wedoo Care? -- Select an answer --Support CoordinatorFriend or FamilyGoogleOnline AdsFacebookPrint Media (Wedoo care Brochures, Newspapers etc.)Other If other, please describe Shift Requirements What Wedoo Care services do you require? Support CoordinationSupport WorkersAccommodation Services (Supported Living) List the type of support you need In-home supportCommunity accessPersonal careRespite CareOther If other support is required, please describe
