Suburb: own home/purchasing private rental Post code: independent living unit public rental supported accommodation other Council: Postal (if diff): Telephone: (h) Country of Birth: (w) Main Language spoken at home: (m) Indigenous status: Email: Not indigenous Aboriginal Torres Strait Islander Prefer not to say Living arrangements: alone living with others living Department of Veterans Affairs card status: living with family (includes spouse) Not a DVA card holder Accommodation setting: Gold Card White Card Other DVA card Employment Status: Full CARING time ROLE Part ASSESSMENT: time Casual Seasonal Not in paid employment Primary Diagnosis/Disability: Time spent caring in a typical week: Does Under the 20 client/care hrs 20 40 recipient hrs over have 40 dementia? hrs – Yes suspected, but not diagnosed No Comments: In a typical week, what does the carer do for the CR? Personal care (eg. showering and dressing) Does the client/care recipient have an NDIS plan? Housework Yes No Transport Managing finances GP Details Meal Preparation Dr: Shopping Address: Feeding (assisting client/care recipient to eat) Ph: Continence management Transfers (assisting with getting in/out of chairs/cars etc) Medication administration Emotional support Daily routine support Behaviour support/management Advocacy Liaison with agencies Phone contact with the client/care recipient ALL OF THE ABOVE Does the have a disability? Does the carer have any of the following: Difficulties or stress relating to their caring role Please specify: Health conditions of their own Please specify: Goals relating to their caring role or access of support services Please specify: Any details not recorded elsewhere Comments: Does the carer drive? What is the main reason for your registering as a carer? To access respite in case of emergency To access respite now To make use of Carer Support’s groups and activities
Suburb: Post code: Council: Postal (if diff): Telephone: (h) (w) (m) Email: Living arrangements: living alone living with others living with family (includes spouse) Accommodation setting: own home/purchasing private rental independent living unit public rental supported accommodation other Country of Birth: Main Language spoken at home: Indigenous status: Not indigenous Aboriginal Torres Strait Islander Prefer not to say Department of Veterans Affairs card status: Not a DVA card holder Gold Card White Card Other DVA card Employment Status: Full time Part time Casual Seasonal Not in paid employment Primary Diagnosis/Disability: Does the client/care recipient have dementia? Yes suspected, but not diagnosed No Comments: Does the client/care recipient have an NDIS plan? Yes No GP Details Dr: Address: Ph: CARING ROLE ASSESSMENT: Time spent caring in a typical week: Under 20 hrs 20 – 40 hrs over 40 hrs In a typical week, what does the carer do for the CR? Personal care (eg. showering and dressing) Housework Transport Managing finances Meal Preparation Shopping Feeding (assisting client/care recipient to eat) Continence management Transfers (assisting with getting in/out of chairs/cars etc) Medication administration Emotional support Daily routine support Behaviour support/management Advocacy Liaison with agencies Phone contact with the client/care recipient ALL OF THE ABOVE Does the have a disability? Does the carer have any of the following: Difficulties or stress relating to their caring role Please specify: Health conditions of their own Please specify: Goals relating to their caring role or access of support services Please specify: Any details not recorded elsewhere Comments: Does the carer drive? What is the main reason for your registering as a carer? To access respite in case of emergency To access respite now To make use of Carer Support’s groups and activities
registration-form-sept-2018.docx