Form Page - Residency by Dillons

Application for Residency

Thank you for your interest in placement at Residency by Dillons. Your Completion of this form will ensure you are included on the waiting list at your preferred Residency by Dillons location. All information provided will be treated as highly confidential.

Please include a copy of a current ACCR or My Aged Care Support Plan with this Application for Residency.

Applicant’s Name(Required)

Please select your preferred location/s(Required)

Fremantle, Western Australia

Mount Lawley, Western Australia

Narrogin, Western Australia

Tin Can Bay Queensland

What type of care are you applying for?

Please Select Care Type(Required)

Permanent care now

Permanent care in the future

Respite care now

Respite care in the future

Respite care now start date(Required)

Please enter approx start date that respite care might be required.

Respite care now finish date(Required)

Please enter approx date in future that respite care would finish

Permanent care now start date(Required)

Please enter approx start date that permanent care might be required

Permanent care now finish date(Required)

Please enter approx start date in future that respite care might be required

Possible future date for permanent care

Possible future permanent care start date(Required)

**Please note if you wish to proceed with the placement, admission will generally need to occur within 48-72 hours from time of offer. **

Possible future permanent care finish date(Required)

**Please note if you wish to proceed with the placement, admission will generally need to occur within 48-72 hours from time of offer. **

How did you hear about Residency by Dillons?

We would love your feedback

Recommendation by friend or family

Website

My Age Care Website

Recommendation by doctor, hospital, or other health provider

Printed Brochure/Leaflet

Other – please specify

Myself

Someone Else

Applicant’s Details

Name(Required)

Title Given Names(s) Surname

Preferred Name(Required)

Date of Birth(Required)

Gender(Required)

Male

Female

Intermediate/Intersex/Unspecified

Marital Status(Required)

Married

De Facto

Widowed

Single

Country of Birth(Required)

Language(s) Spoken(Required)

Interpreter Required?(Required)

Yes

Do you identify as Aboriginal or Torres Strait Islander? (Required)

Aboriginal

Torres Strait Islander

Both

Are you listed on the Electoral Roll?(Required)

Yes

Do you have an Advanced Health Directive?(Required)

Yes

Is there a Guardianship Order in place?(Required)

Yes

Do you currently have a funded Home Care Package?(Required)

Yes

Who is your Home Care Provider:

If you confirmed "Yes" that you currently have a funded home care package, please fill in details below

Company(Required)

Contact Person:

Phone Number(Required)

Email(Required)

Current Home Address (not Hospital or TCP address)

Enter Address Details(Required)

Street Address Suburb City State Post Code

Phone(Required)

Are you coming to Residency by Dillons from:

From what location(Required)

Living at home

Transitional Care

An Aged Care Facility

Coming from transitional care/please specify details(Required)

Date of Transitional Care(Required)

An Aged Care Facility (Required)

Please specify name of Facility

What date did you enter residential aged care?(Required)

Do you wish to request a specific room or room type?

Please enter details regarding specific room or room type.

Have you discussed a RAD?(Required)

Yes

Please indicate amount of RAD(Required)

You have indicated that you have discussed a RAD. Please indicate amount

Contact 1

Name(Required)

First Middle Surname

Enter Address Details(Required)

Street Address Suburb City State Post Code

Relationship to Applicant: (Required)

Phone Number(Required)

Phone Number

Email(Required)

Is this person:(Required)

Enduring Power of Attorney

Guardian

Administrator

Enduring Power of Guardianship

None of the Above

Contact 2 (Not Mandatory)

Please select

Contact 2

Name(Required)

First Middle Surname

Enter Address Details(Required)

Street Address Suburb City State Post Code

Phone Nbr 1(Required)

Phone Nbr 2

Email(Required)

Is this person:

Enduring Power of Attorney

Guardian

Administrator

Enduring Power of Guardianship

None of the Above

Responsibilities

Who is responsible for billing arrangements and payments?(Required)

Who do we discuss care and medical needs with?(Required)

Who will sign the agreement?(Required)

Current Medical Practitioner (GP)

Name(Required)

First Last

Practice Name:(Required)

Address(Required)

Street Address Address Line 2 City State Postcode Country

Email(Required)

Has the GP agreed to visit the facility if required?(Required)

Yes

Do you want to transfer to the facility’s GP?(Required)

Yes

Private Health Insurance

Do you have Private Health Insurance?(Required)

Yes

Company(Required)

Type(Required)

Private Health Insurance Membership Number

Ambulance Fund

Do you belong to an ambulance fund?(Required)

Yes

Ambulance Fund Number(Required)

Pension/Medicare

Do you receive a means-tested Australian Pension?(Required)

If yes, please select any applicable items below.

Yes

Pension

Full Aged Pension

Part Aged Pension

Disability Pension

Widow’s Pension

Blind Pension

DVA Gold Card

DVA White Card

Overseas Pension (Country)

Pension from overseas country(Required)

If you indicated that you have a pension from an overseas country, please enter which country this is above.

Pension Card/DVA Number

Medicare Number (Required)

Medicare Ref#(Required)

Medicare Number Expiry Date(Required)

Do you receive any NDIS funding?(Required)

Yes

Vaccinations

Have you received the influenza vaccination?(Required)

Yes

Date of Most Recent Vaccination(Required)

Have you received the COVID – 19 vaccinations(Required)

Yes

Date of Dose 1

Date of Dose 2

Date of Dose 3

Date of Dose 4

Income and Assets

Have you lodged the Centrelink or Department of Veteran’s Affairs (DVA) Income and Assets Assessment?

Yes

Date of Submission

Receipt Number

Assessment received from Services Australia?(Required)

Yes

Pending

Please attach assessment from Services Australia. (You will be able to do this at the end of this form)

Do you own your own home?(Required)

Yes

If you own your own home,will a spouse or dependent family member continue to live in this house after you enter residential care?(Required)

Yes

Income and Assets Assessment

If you have not received the Income and Assets Assessment, please complete the following table to the best of your ability. If you have a partner, please supply your combined assets information.

** Completing your Centrelink Income and Assets Assessment is not mandatory, however if you choose not to complete the assessment, you will not be eligible for any Government assistance towards your accommodation and care costs, and you will be liable to pay the maximum means tested care fee on admission regardless if your financial status**

TYPE OF INCOME PER ANNUM

Income support payment from the Australian Government (eg. Age Pension)

Amount

War Widow or Widow Pension/Disability Pension/Carer’s Pension

Amount

Overseas Pension(s)

Amount

Superannuation

Amount

Income from rental properties, business(es), family trust(s), or other, excluding bank interest

Amount

Total Amount of Income per Annum

ASSETS

Home (Estimated Net Market Value) If not occupied by Protected Person

Amount

Savings in Bank Account

Amount

Stocks/Shares

Amount

Term Deposits

Amount

Managed Investments (Superannuation Balance if income stream not commenced)

Amount

Gifting Assets (if you have gifted away amounts above $10,000 in the last year, or $30,000 in the last five years, or gifted your home, include anything above these amounts here as a financial asset)

Amount

TOTAL AMOUNT OF ASSETS

OTHER ASSETS

Amount

Household Contents (typically around $10,000), Car, Caravan, etc.

Amount

Superannuation Balance (if commenced as an income stream)

Amount

Net Retirement Village Entry Contributions/Trust

Amount

Investment Properties (must match income from rental properties)

Amount

Other Assets (provide details)

TOTAL AMOUNT OF OTHER ASSETS

NAME OF PERSON WHO COMPLETED THIS FORM

First Last

FILE UPLOADS

File

Max. file size: 50 MB.

Application for Residency

What type of care are you applying for?

Possible future date for permanent care

How did you hear about Residency by Dillons?

Applicant’s Details

Who is your Home Care Provider:

Current Home Address (not Hospital or TCP address)

Are you coming to Residency by Dillons from:

Contact 1

Contact 2 (Not Mandatory)

Responsibilities

Current Medical Practitioner (GP)

Private Health Insurance

Ambulance Fund

Pension/Medicare

Vaccinations

Income and Assets

Income and Assets Assessment

TYPE OF INCOME PER ANNUM

ASSETS

OTHER ASSETS

FILE UPLOADS

Our Care

Locations

Info Centre

Contact