Western Australia Companion Card Application Form

Eligibility Criteria

Companion Card Application Form Western Australia

There are 4 requirements to be eligible for a Companion Card:

You live in Western Australia; and

Youhaveasignificantdisability,whichmayincludeissuesrelatedtoageingandpsychiatric illness; and

Duetotheimpactofyourdisabilityyouwouldbeunabletoparticipateatmostcommunity venuesoractivitieswithoutattendantcaresupport; and

Yourneedforthislevelofsupportwillbelife-long.

TheCompanionCardisnotissuedtopeoplewhoonlyrequirereassurance,social companyorencouragement. SometimesapersonmayrequireacompanionbutnotbeeligibletoreceiveaCompanion Card.Examplesincludeapersonwhois: -experiencingatemporarydisability -unlikelytorequirelifelongattendantcaresupport -affectedbytheinaccessibilityofaparticularvenue

Yourserviceprovider,healthprofessional,legalguardianoragentmayassistyoutocompletethisform.Pleaseensureyoucompleteallrelevantsectionsasincompleteapplicationscannotbeprocessed.

Step 1. CompleteItems1–4oftheapplicationform.

Step 2. Gettwoidenticalhighqualitycolourpassport-sizedphotographs (seepage2fordetailsofacceptablephotos)

Step 3. Takeyourformandphotosforverificationbyeitheraspecifiedserviceproviderat Item5oraspecifiedhealthprofessionalatItem6.

Step 4. Attachyourphotographstothetopofpage10withapaperclip.

Step 5. CompleteandsigntheapplicantstatementatItem7.

Step 6. Returnthecompletedapplicationformandverified photosto: CompanionCardApplications ReplyPaid1595 OSBORNEPARKBCWA6916

How to Apply

Attendantcaresupportincludessignificantassistancewithmobility,communication,selfcare,orlearning,planninganddecisionmaking,wheretheuseofaids,equipmentoralternativestrategiesdoesnotenablethepersontocarryoutthesetasksindependently.

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Not all people with a disability are eligible for a Companion Card:

PhotographsYoumustincludetwocurrentidenticalcolourpassport-sizedphotographsshowingyourheadandtopofshoulderswithyourapplication. YourphotographwillbeprintedonyourCompanionCard.

ThebackofEACHphotographmustinclude: thenameofthepersoninthephotograph;and thesignatureofthesameserviceproviderorhealthprofessionalwhosignedeither Item5or6ofyourapplicationform.

Acceptable PhotosThefollowingguidelineswillhelpyouprovidesuitablephotographs,sothatyourapplicationisnotdelayedbyhavingtosubmitnewphotographsintherequiredformat.

Colourphotosonly(notblackandwhite) Printedongoodqualityglossphotopaper Nograiny,pixilatedorblurryimages

Assessment of Applications

x x x 335-40mm

45-50m

m

2Page

For more information, please contact the Companion Card WA Office:Tel: 1800 617 337TTY: 9443 3107Email: wa@companioncard.asn.auWeb: www.wa.companioncard.asn.au

Pleaseallowapproximately20workingdaysforprocessing(mayincreaseduringpeakperiods).TheCompanionCardprogramwillassesseachapplicationagainstallofthefoureligibilitycriteriafortheprogram. Ifmoreinformationisneededtodetermineeligibility,theWACompanionCardprogrammay:

contacttheapplicant(orlegalguardian/agent)toaskforadditionalinformation. followupwiththeserviceproviderorhealthprofessionalwhoverifiedtheapplication. requestinformationfromrelevantgovernmentdepartmentsorserviceprovidersto assistwiththeassessmentofyourapplication.

PleasenotethatcompletionofanapplicationformdoesnotguaranteeaCompanionCardwillbeissued.

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Title:

Item 1. Applicant details

TheCompanionCardwillonlybeissuedinthenameofthepersonwiththedisability. Oneapplicationmustbecompletedperapplicant.

FirstName(asitisonofficialdocumentationsuchasabirthcertificate):

Surname:

DateofBirth:ddmmyyyy

Mr Mrs Ms Miss Other

Age:

MaleFemaleGender:

Email:

Telephonenumber:

TelephoneTypewriter/(TTY)ifapplicable:

Yes NoIsyourdisabilitypermanent?

IfyourdisabilityisnotpermanentyoudonotmeettherequirementstoreceiveaCompanionCard–donotproceed.Contactthefreecallnumber1800617337forfurtherinformation.

ResidentialAddress:

Suburb:

State: Postcode:

PostalAddress(ifdifferentfromabove):

Suburb:

State: Postcode:

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4Page

Item 2. Describing your disability

Whatisyourprimarydiagnosis?

Doyouhaveanyothermedicalconditionsthatarerelevanttoyourneedforattendantcaresupporttoparticipateatmostcommunityvenuesoractivities?

Item 3. Disability specific information

TobeeligibleforaCompanionCardyoumustdemonstratewhyyourdisabilityorconditionmakesyoupermanentlyunabletoparticipateatmostcommunityvenuesandactivitieswithoutsignificantattendantcaresupport.

Do you require attendant care support with any of the following in order to take part in community events and activities?

Mobility(thisisaboutyourabilitytomovearound,forexample,yourneedforattendant caresupporttonavigateyourwheelchair,assistyoutoaccessyourseatorothervenuefacilities.)

Yes No

A

IfYes,pleaseprovidespecificexamplesaboutyourmobilityrequirements.Atcommunityactivities,Irequireattendantcaresupportto:

Communication(thisisaboutunderstandingandbeingunderstoodbyothers,forexample, yourneedforattendantcaresupporttopurchaseticketsoraccessyourseat.

Yes No

B

IfYes,pleaseprovidespecificexamplesaboutyourcommunicationrequirements.Atcommunityactivities,Irequireattendantsupportto:

Learning, planning and decision making(thisisaboutyourabilitytoplanandcarryout anactivityinthecommunityindependently,forexample,yourneedforattendantcare supporttoassistwithhandlingmoney,andguidingyoutoknowwhereandwhattodoata particularevent).

Additional comments Isthereadditionalinformationthatyouwouldliketoprovidetosupportyourapplication foraCompanionCard?Forexample,detailsofservicesandsupportsyoureceive(respite, therapy,localareacoordination)ordetailsofformalassessments.

Self care(thisisaboutdailypersonalcaretaskswhereforexampleyoumayrequiresupport fromacompaniontodressortoilet.)

C

IfYes,pleaseprovidespecificexamplesaboutyourselfcarerequirements.Atcommunityactivities,Irequireattendantsupportto:

Yes No

D

E

IfYes,pleaseprovidespecificexamplesaboutyourlearning,planninganddecisionmakingrequirements.Atcommunityactivities,Irequireattendantsupportto:

Yes No

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6Page

Do you currently receive any of the eight specific services or supports listed below?

Ifyouareunsure-checkwithyourLACorServiceProvider

Yes,pleaseindicatebelow

No,pleasegostraighttoItem6onpage8.YoudonotneedtocompleteItem5.

(youcantickmorethanonebox)

AccommodationSupportservice,fundedorprovidedbytheDisabilityServicesCommission

IntensiveFamilySupportpackage,fundedorprovidedbytheDisabilityServicesCommission

AlternativestoEmploymentprogram,fundedorprovidedbytheDisabilityServicesCommission

SupportedAccommodationAssistanceProgram,fundedorprovidedbytheOfficeofMentalHealth

ResidentialAgedCareServices,fundedorprovidedbytheAustralianGovernment

ExtendedAgedCareatHomepackage,fundedorprovidedbytheAustralianGovernment

CommunityAgedCarepackage,fundedorprovidedbytheAustralianGovernment

Veteran’sAffairsAttendantAllowance,fundedorprovidedbytheAustralianGovernment

Item 4. Service & Supports

Ifyouhaveindicatedyoureceiveaserviceorsupport,pleasetakethisformtogetherwithtwoidenticalcolourpassport-sizedphotographstoyourServiceProviderorLACtocompleteItem5.

To be completed by Service Provider, or LAC: Service and Supports verification Pleaseverifythattheapplicantcurrentlyreceivestheselectedservices orsupportslistedatItem4.

Service provider or LAC contact details

7Page

Yes No

B

A

Name:

Position:

Employer/OrganisationName:

Address:

TelephoneNumber:

Email:

Suburb: Postcode:

Photographs Pleaseverifythatbothpassportsizedphotographssuppliedareoftheapplicant,bywritingon thebackofthephoto’s: thisisaphotoof(insertthenameofthepersoninthephotograph) yoursignature Service Provider or LAC Declaration Iconfirmthatmysignaturebelowverifies all of the following(pleasetick):

IhavereadandunderstandtheCompanionCardeligibilitycriteria; Ihavereadalloftheinformationcontainedinthisformandverifythatitiscorrecttothe bestofmyknowledge;

Iamnottheapplicantoranimmediatefamilymemberoftheapplicant;

IagreetoofferallreasonableinformationtoassisttheCompanionCardprogramtodetermine theapplicant’seligibility;

Iunderstandthatitisanoffensetoprovidefalseormisleadinginformationinthisapplication.

Applicant Note: If you receive one of the eight specific services and your service provider has completed this section, PLEASE GO TO ITEM 7. You do not need to complete ITEM 6.

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C

Date: //

Signature: OrganisationStamp(ifavailable):

Item 5. Service Provider or LAC details

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Item 6. Health Professional Details

A

B

Yes No

C

Applicantnote:ThisitemisonlytobecompletedifyoudonotreceiveaserviceorsupportaslistedatItem4 Takethisformtogetherwithtwoidenticalcolourpassport-sizedphotographstooneoftheHealthProfessionalslistedbelowforverification.

To be completed by Health Professional.

PleaseindicatewhichHealthProfessionalcategoryappliestoyou:

RegisteredMedicalPractitioner

Registered Nurse

RegisteredPhysiotherapist

RegisteredPsychologist

QualifiedOccupationalTherapisteligibleformembershipwithOccupationalTherapyAustralia

QualifiedSocialWorkereligibleformembershipwiththeAustralianAssociationofSocialWorkers

QualifiedSpeechPathologisteligibleforpracticingmembershipwithSpeechPathologyAustralia Doestheapplicantrequirelifelongattendantcaresupporttoparticipateatmost communityvenuesandactivities?(Attendantcaresupportincludessignificantassistance withmobility,communication,selfcare,orlearning,planninganddecisionmaking,wherethe useofaids,equipmentoralternativestratgiesdoesnotenablethepersontocarryoutthese tasksindependently)

Iftheneedforattendantcaresupportisnotpermanent,theapplicantisnoteligibletoreceiveaCompanionCard. Pleaseprovidedetailsconfirmingtheapplicant’slifelongneedforattendantcaresupportout inthecommunityinthearea’sof:mobility,communication,self-careorlearning,planningand decisionmaking.

E

D Pleaseverifythatbothpassportsizedphotographssuppliedareoftheapplicant, bywritingonthebackofthephoto’s: thisisaphotoof(insertthenameofthepersoninthephotograph) yoursignature

HealthProfessionalcontactdetails

Pleaseprovideyourcontactdetailsbelow:

Name:

Position:

EmployerofBusinessName:

Address:

DaytimeContactNumber(s):

Email:

Health Professional Declaration

Iconfirmthatmysignaturebelowverifiesallofthefollowing:

IhavereadandunderstandtheCompanionCardeligibilitycriteria;

Ihavereadalloftheinformationcontainedinthisformandverifythatitiscorrecttothebest ofmyknowledge;

Iamnottheapplicantoranimmediatefamilymemberoftheapplicant;

IagreetoofferallreasonableinformationtoassisttheCompanionCardprogramtodetermine theapplicant’seligibility;

Iunderstandthatitisanoffensetoprovidefalseormisleadinginformationinthisapplication.

F

Date: //

Signature: Professionalregistrationnumber/membershipnumber/stamp:

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10Page

Item 7. Applicant Statement

Thisitemistobecompletedbytheapplicantortheirlegalguardian/agent.

Iconfirmthatmysignatureonthefollowingpageverifiesthat:

IauthorisetheCompanionCardprogramtoverifytheinformationcontainedin thisformandtoobtainfurtherinformationrelatingtomyeligibilityforaCompanion Card.Thismayincluderequestinginformationheldindatabasesbygovernment departments,organisationsandagencies;

IagreethatHealthProfessionalsorServiceProvidersmaydiscloseinformation aboutmetotheCompanionCardprogramtoassistwiththeassessmentofmy application;

IhaveapermanentdisabilityandIwillalwaysrequireattendantcaretypesupport toparticipateatmostcommunityvenuesandactivities;

IwilladvisetheCompanionCardprogramofanychangesinmycircumstances thatmayaffectmyeligibilitytoholdacard;

Icertifythattheinformationinthisapplicationiscorrect;andIunderstandand acceptthecardholderTermsandConditions.

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Attachphotohere

45mm

35mm

Affix verified photographs here using a paper clip or fold back clip.Do NOT use tape, staples, glue or pins

11Page

You MUST provide one of the following signatures: ApplicantSignature(forapplicantsover18yearsofage)

OR

LegalGuardian/AgentSignature

Date://

Date://

LegalGuardian/AgentName(andrelationshiptotheapplicant)

Telephonenumber: TelephoneTypewriter/TTY(ifapplicable):

IconsenttoparticipatinginmediaopportunitiesandevaluationoftheCompanionCardprogram.

Yes No

Person who completed this form (if different from above)

Name(andrelationshiptotheapplicant)

Telephonenumber:

Privacy StatementInaccordancewithNationalPrivacyPrinciple(NPP04:DataSecurity),informationcontainedintheapplicationformwillnotbedisclosedtoanyotherorganisation:www.privacy.gov.au

Pleaseensureyoucompleteallrelevantsectionsasincompleteapplicationscannotbeprocessed.

Items1-4havebeencompletedbyyouoryourlegalGuardian/Agent.

YourapplicationformhasbeenverifiedbyeitheraspecifiedserviceprovideratItem5 oraspecifiedhealthprofessionalatItem6.

Thesamehealthprofessional/serviceproviderhasverifiedandsignedthebackofyour passportsizedphotographs.

Yourphotographsareattachedwithapapercliptothetopofpage10.

Item7hasbeencompletedandsignedbytheapplicantorlegalGuardian/Agent.

Applicant Checklist

12Page

Please return the completed application form to: Companion Card ApplicationsReply Paid 1595OSBORNE PARK BC 6916

Companion Card Program WAUnit1,59WaltersDrive,OsbornePark.Replypaidpost:POBox1595, OsborneParkBCWA6916.Tel:1800617337,TTY:94433107,Fax:92425044Web:www.wa.companioncard.asn.auEmail:wa@companioncard.asn.au

Applicant Note:

Allowapproximately20workingdaysforprocessing(mayincreaseduringpeakperiods).

CompletionofanapplicationformdoesnotguaranteeaCompanionCardwillbeissued.

Applicationswillbeassessedagainstthefoureligibilitycriteriaoutlinedonpage1.