Commonwealth Respite & Carelink Centre North Metro (WA) Phone: 1800 052 222

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Carer Registration Form Confidentiality and Privacy Agreement The information you provide may help us to support you in your caring role. The Australian Government requires us to ask some of these questions to help improve and plan for future services. We will not pass on any identified information without your consent.

To enable us to provide services to support you in your caring role do you give permission for us to share information with other agencies? Carer: Yes No Care Recipient: Yes No You can see our Privacy and Confidentiality policy statement on our website: https://ilc.com.au/privacy/

Please note, you can withdraw your permission at any time by contacting comcarelink@ilc.com.au or by phoning 1800 052 222.

Once we receive your completed form we will be in contact with you within 5 business days. During this time if your needs change and you require urgent respite assistance, please phone 1800 052 222.

Referrer Details (if not Primary Carer): Name: Agency:

Phone number: Email address:

About Primary Carer Do you provide most assistance to the person who needs care?: Yes, Primary Carer How long have you been in your caring role?

First name: Last name:

Preferred name:

Telephone: (H) (W) (M)

Email: Permission to email Yes No

Home address:

Suburb: Postcode:

Postal Address: (If different)

Your DOB: Gender: Female Male Intersex Prefer not to say

Marital status: Married / Defacto Never Married Separated/Divorced Widowed

Your Country of Birth: Residency Status: Australian citizen Permanent resident

Other

Main language spoken at home: Second language: Is an Interpreter required: Yes No Preferred language:

Indigenous Status: Aboriginal Torres Strait Islander Both Aboriginal & Torres Strait Islander Neither

Employment status: Full time Part time Casual Seasonal Not in paid employment

Government pension status: No pension/benefit Carers Pension Carers Allowance Aged Pension Disability Pension

Commonwealth Respite & Carelink Centre North Metro (WA) Phone: 1800 052 222

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Department of Veterans Affairs status: Not a DVA card holder DVA Gold Card DVA White Card Other DVA Card Your DVA Number: Accommodation Type: Own home/purchasing Independent Living Unit

Public rental Private rental

Supported accommodation Other

Household Composition: Living alone Sole parent with dependants

Couple Couple with dependents

Group (Related adults) Group (Unrelated adults)

About Your Caring Role What is your relationship to the person you care for?

Spouse / Partner Son / Daughter

Parent / Guardian Brother / Sister

Other please provide details:

How many People do you care for? (if you wish to register more than 1 person being cared for please complete Care Recipient Details for each person)

In a typical week, what do you do for the person/s being cared for? All of the below

Personal care (e.g. showering and dressing)

Housework

Transport

Managing finances

Meal preparation

Shopping

Feeding (assisting care recipient to eat)

Continence management

Assisting with getting in/out of chairs/cars etc.

Medication support/administration

Emotional support

Daily routine support

Behaviour support/management

Advocacy

Communication

Liaison with agencies

Phone contact with the care recipient

How much time in a typical week do you spend in caring role? Under 20 hrs 20 – 40 hrs over 40 hrs Do you have any challenges related to your caring role? Yes No If yes, please describe:

Do you have any health conditions of your own? Yes No None Physical Chronic Health Mental health Sensory Intellectual/Learning Other If yes, please describe:

Do you have any goals related to your caring role? Yes No If yes, please describe:

Commonwealth Respite & Carelink Centre North Metro (WA) Phone: 1800 052 222

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How do you currently access your community? Own transport Public transport Taxi

Other, please describe: Please provide any other relevant information about your caring role here:

What is your main reason for registering as a Carer with CRCC? To access assistance with respite now To access assistance with respite in case of emergency To learn more about available carer education and support To find out how Independent Living Centre can assist me

Other, please describe:

Care Recipient Details – About the person you provide care to First name: Last name:

Preferred name:

Telephone: (H) (W) (M)

Home address:

Suburb: Postcode:

DOB: Gender: Female Male Intersex Prefer not to say

Marital status: Married / Defacto Never Married Separated/Divorced Widowed

Country of Birth: Residency: Australian citizen Permanent resident Other

Main language spoken at home: Second language: Is an interpreter required: Yes No Preferred language:

Indigenous Status: Aboriginal Torres Strait Islander Both Aboriginal & Torres Strait Islander Neither

Employment status: Full time Part time Casual Seasonal Not in paid employment

Government pension status: No pension/benefit Aged Pension Disability Pension Other

Department of Veterans Affairs status: Not a DVA card holder DVA Gold Card DVA White Card Other DVA Card

DVA Number:

Please indicate and provide details of Care Recipients diagnosis / disability Frailty with ageing: Physical: Intellectual/learning: Sensory/speech: Autism: Mental Health Condition: Medical Condition: Other:

Commonwealth Respite & Carelink Centre North Metro (WA) Phone: 1800 052 222

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Has the Care Recipient been diagnosed with dementia? Yes Suspected, but not diagnosed No

Has the Care Recipient been diagnosed with epilepsy? Yes No If yes, type of epilepsy: When was their last seizure? Frequency of seizures: Describe epilepsy management plan:

Has the Care Recipient been diagnosed with diabetes? Yes No If Yes, how is this managed? Insulin Tablets Diet Other Please describe:

Does the Care Recipient have any allergies? Yes No If yes, please describe:

Does the Care Recipient experience any challenging reactions to their environment? Yes No If yes, please describe any triggers and support strategies used:

Please provide additional details of any other diagnoses and/or specific care needs:

General Practitioner: Name of Doctor: Name of Medical Centre: Address of Medical Centre:

Phone:

Alternate Contacts: Alternate Carer – a person who shares the caring responsibilities with you.

First Name: Last Name: Relationship to Carer:

Home Phone: Mobile: Work Phone:

Is this person aware that they have been nominated? Yes No

Emergency Contact: Please nominate who you authorise to make decisions on your behalf, if we were unable to contact you during a respite service. First Name: Last Name: Relationship to Carer:

Home Phone: Mobile: Work Phone:

Is this person aware that they have been nominated? Yes No

Commonwealth Respite & Carelink Centre North Metro (WA) Phone: 1800 052 222

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Emergency Response:

How would you like us to respond if your Care Recipient does not answer the door for a scheduled in-home respite service?

Please be advised that your emergency contact (listed above) and/or Police Services may be contacted if there are concerns for the care recipient’s wellbeing or safety due to them not answering the door.

In some circumstances, an ambulance may be called to attend. Please be advised that funding is not provided for ambulance attendance.

Assessments Completed For person with disability or mental health condition: Name of DSC Local Coordinator/Planner:

Phone number for DSC Local Coordinator/Planner:

NDIS Status: Eligible for NDIS Assessment in progress NDIS Plan Approved N/A

For person over the age of 65 with dementia or age related care needs: My Aged Care #: AC Residential Respite Referral Code:

Services Currently Received Name of Agency Type of Service/Support Frequency of Support

Type of support: HACC Home Care Package 1/2 Home Care Package 3/4

Details of service required: Briefly describe support required and the reason for your request.

Office use only

Entered in CM4

Welcome Pack Sent Carer Liaison Officer

Follow-up completed