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1300 243 227

Who We Are
How We Help
Getting Started
Resources
Where to find us
Contact Us

Participant Admission Form

Home Participant Admission Form

Step 1 of 3

33%

Franchise ID

Senior Helpers Office

PART 1A PERSONAL DETAILS

Participant Contact Information

First Middle Last

Preferred Name

Phone Number

Mobile

Preferred call back time

Morning

Afternoon

Evening

Email

Participants Address

Street Address City State / Province / Region ZIP / Postal Code

Preferred method of Communication or Correspondence

Phone Call

Text Message

Email

Mail

Personal Details

Date Of Birth

MM slash DD slash YYYY

Gender

Preferred Pronouns

He/ Him/ His

She/ Her

They/ Them

Ethnicity

Aboriginal

Torres Strait Islander

Other

Religion/ Spirituality

Languages Spoken

Preferred Language

Previous Occupation (if applicable)

AUSLAN/ Language Interpreter required?

Yes

No

Previous Occupation (if applicable)

Participant Status

Complete only if Participate Transferring

Previous Provider Name

First Last

Phone

Email

Contact Person

Transfer date confirmed

Yes, email received confirming transfer date

No, need to contact previous provider

Funding Details

Support At Home Package

Level 1

Level 2

Level 3

Level 4

1

2

3

4

5

6

7

8

Care Recipient ID (ACMPS)

MAC Referral Code

My Aged Care Number

Income Tested Fee (ITF) Daily Amount

No

Yes

Centrelink letter sighted/copy

Daily Amount

Carer Status

No Carer

Co-Carer

Resident Carer

Supplement(s) & Daily Rate

Dementia

Oxygen

Enteral Feeding

Veterans

Rural & Remote

Home Care Agreement

Completed

Signed

Agreement/Contract Date

MM slash DD slash YYYY

Living Status

Relationship Status

Spouse/Partner’s Name

First Last

Living Arrangements

Lives alone

Second Choice

Lives with others

Medicare, Veterans Affairs & Ambulance

Medicare Number

Expiry

MM slash DD slash YYYY

Pension Card Number

Veterans Affairs Card

Number

Person 1 / Next of Kin

Relationship to Participant

Emergency Contact

Name

First Middle Last Preferred

Email

Mobile

Home Phone

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Permission to Discuss

Health

Finances

Incident

Other

Preferred Method of Communication and Correspondence

Phone Number

Text Message

Email

Mail

Person 2

Relationship to Participant

Emergency Contact

Given Name

First Middle Last

Phone

Home Phone

Email

Address

Same as previous

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Permission to Discuss

Health

Finances

Incident

Other

Preferred Method of Communication and Correspondence

Phone Number

Text Message

Email

Mail

Registered Supporters

Given Name

First Middle Last

Home Phone

Phone

Email

Address

Same as previous

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Permission to Discuss

Health

Finances

Incident

Other

Preferred Method of Communication and Correspondence

Phone Number

Text Message

Email

Mail

PART 1C LEGALITIES

Power of Attorney

PERSON 1 / NEXT OF KIN

Power of Attorney (Financial)

Enduring Power of Attorney (Financial & Personal)

Enduring Power of Attorney (Medical)

Supportive Attorney

If no, make a note to follow-up. It is important you have a copy of file.

Given Name

First Middle Last

Phone

Home Phone

Email

Address

Same as previous

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

PERSON 2

PERSON 2 / NEXT OF KIN

Power of Attorney (Financial)

Enduring Power of Attorney (Financial & Personal)

Enduring Power of Attorney (Medical)

Supportive Attorney

If no, make a note to follow-up. It is important you have a copy of file.

Given Name

First Middle Last

Phone

Home Phone

Email

Address

Same as previous

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Guardianship

Guardianship in place

Limited Order

Plenary Order

Enduring

Same as Next of Kin

Same as Carer

Same as Emergency Contact

Company/ Organisation

Given Name

First Middle Last

Phone

Home Phone

Email

Address

Same as previous

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Advance Health/Care Planning

SH Staff: Advance Care Planning Australia lists the requirements by state and territory for individual’s wanting to record their choices for future health care.

Do you have an: Advance Health Directive (Qld) or Advance Care Directive (NSW/SA/VIC/WA)

Have you created an advance care plan?

Do you have funeral arrangements in place?

Financial Management & Funding Statements

Do you manage your own money and pay the bills?

Yes

No

Without help

Completely unable

With some help

Who manages your finances?

Preferred method for receiving funding statements

Email

Postal Address

Jessica Ponting

Operations Manager

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Christina Chartrand

Vice President of Training

Christina has over 25 years’ experience of training and teaching. She has created numerous training programs on a variety of topics for families, employees, managers and business owners, including the Senior Gems® and Parkinson’s Care Programs.

Robert Sharkey

Chief Financial Officer

Robert came to Senior Helpers in 2013 with an extensive background in finance and operations across many businesses, including Medicare.

Mari Baxter

Senior Vice President of Operations

Mari is responsible for managing the Business Development Team. She has been with Senior Helpers for over 10 years with 14 prior years’ experience as a successful business owner and entrepreneur.

Peter Ross

Chief Executive Officer & Co-Founder

Peter co-founded SH Franchising with Tony Bonacuse in 2004 and is the current CEO for Senior Helpers. He has led the organisation to become a national leader in non-medical home care in the USA. He is also the past President of the Home Care Association of America’s board of directors.

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Contact Head Office

163 Sheridan Street, Cairns North, QLD 4870

1300 243 227

Monday – Friday: 8:30am – 5pm

07 4281 6816

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