Digital Application Form for permanent accommodation & care

Thank you for considering Southern Cross Care (Tasmania) Inc. as your new home.

Southern Cross Care (Tasmania) Inc. is dedicated to partnering with each individual who chooses to make one of our homes their home, and delivering high-quality care in a positive and supportive environment. We encourage you to ask as many questions as you like throughout your application process.

To ensure your application reflects your care needs, preferences and accommodation requirements as accurately as possible, please complete as much of this form as you can to the best of your ability.

If you need help filling out the form, please phone us on (03) 6146 1800 or email us at enquiries@scctas.org.au

Privacy of your personal information held by Southern Cross Care

The information collected on this form will only be:

used in connection with your application for residential care placement
be accessed by Southern Cross Care staff to the extent necessary to perform their duties and will not be released to a third party without your consent.

If you do not proceed to admission to a Southern Cross Care Residential Care Home all documents will be securely disposed of.
A complete Southern Cross Care Privacy Statement is available on request.

2. Time Frame for Your Move to Residential Care

Please indicate the likely time-frame you are seeking for residential care placement:(Required)

Urgent/as soon as possible

Within three months

Three – six months

Six months and over

3. Personal Information

Completing this section will assist us with getting to know more about you and your family/representatives.

3.1 Your Personal Details

Title(Required)

Name of Applicant(Required)

First Middle Last

Date of birth(Required)

Gender(Required)

Male

Female

I use a different term

Gender information

3.2 Marital Status

Marital status(Required)

Married (Registered or defacto)

Divorced

Never Married

Separated

Widowed

Name of spouse/partner(Required)

First Last

Are you and your spouse/partner applying jointly for Southern Cross Care Residential Care?(Required)

Yes

No

You will each need to complete your own Southern Cross Care Application Form.

3.3 Your Cultural Information

Country of Birth(Required)

Indigenous status(Required)

Unknown

Aboriginal

Torres Strait Islander

Neither

(tick all that apply)

Languages Spoken

Interpreter required

Yes

No

3.4 Your Current Location

Current location type(Required)

Private Residence

Other Residence (eg with family)

Hospital

Non-Southern Cross Care residential care home

Respite

Private residence address(Required)

Street Address Address Line 2 City State Postcode Country

Other residence address(Required)

Street Address Address Line 2 City State Postcode Country

Hospital name(Required)

Non-Southern Cross Care residential care home name(Required)

Date of Admission to non-Southern Cross Care residential care home(Required)

Respite name(Required)

Date of Admission to Respite(Required)

3.5 Your Contact Information

Phone contact type(Required)

Mobile phone

Home phone

Either/Both

Home phone (including area code)(Required)

Mobile phone(Required)

Email(Required)

Contact Address(Required)

Street Address Address Line 2 City State Postcode Country

3.7 Nominated Family Spokesperson

In the event where we need to communicate an event quickly with your family and loved ones, or that may result in a high volume of incoming phone calls to the home’s reception (e.g. COVID-19, evacuation, lockdown), the dedicated Family Spokesperson Protocol will be enacted. The role of the Family Spokesperson is to be our single point of contact for updates about the situation or to receive news on your care and they will be responsible for sharing that information outward to other family members and loved ones.

Each applicant is to nominate a dedicated Family Spokesperson prior to moving into a Southern Cross Care Home. Should a situation/event arise, Southern Cross Care will contact the Family Spokesperson to set up a mutually agreed schedule of communications where our team will provide an update on the situation. The Family Spokesperson is then responsible for communicating updates about the event/incident at the home, to the rest of their family, friends and loved ones. The reason we do this is to avoid congested phone lines and to ensure no family misses out on regular updates due to a high level of incoming phone calls. If we are unable to reach the Family Spokesperson for some reason at the scheduled time, we will leave a message, text, or email them to let them know when we will call back again.

If our residents have their own mobile device or personal landline, they can of course communicate with family as they choose, the Family Spokesperson’s role is to receive and share information they would normally receive from our team members.

My nominated family spokesperson is(Required)

My Primary Representative

My Secondary Representative

Someone else. Enter their details below.

Name of nominated family spokesperson(Required)

First Last

Your relationship to nominated family spokesperson(Required)

Nominated family spokesperson phone type(Required)

Nominated person can be reached by mobile

Nominated person can be reached by mobile, but is best reached during the day by a different phone

Nominated person can only be reached by daytime phone

Nominated family spokesperson mobile phone(Required)

Nominated family spokesperson daytime phone(Required)

Nominated family spokesperson email(Required)

Address of nominated family spokesperson(Required)

Street Address Address Line 2 City State Postcode Country

Family Spokesperson understands their responsibility to disseminate information to the extended family and friends.(Required)

Yes

The nominated person above understands their responsibility as Family Spokesperson.(Required)

Yes

3.8 Current General Practitioner

GP name(Required)

First Last

GP practice name(Required)

GP phone type(Required)

GP can be reached by mobile

GP can be reached by mobile, but is best reached during the day by a different phone

GP can only be reached by daytime phone

GP mobile phone(Required)

GP daytime phone(Required)

GP email(Required)

GP Address(Required)

Street Address Address Line 2 City State Postcode Country

Is your GP willing to continue care if you move to a Southern Cross Care Residential Home?(Required)

Yes

No

4. Pension and Medicare Information

Completing Sections 4 and 5 will assist us with determining your financial status so that we can provide you with draft fees and costs and answer any queries or concerns you may have.

4.1 Your Pension Details

Australian Pension(Required)

Yes

No

Type of Australian Pension(Required)

Full

Part

Aged

DVA

Type of Non-Australian Pension(Required)

Pension Card No.(Required)

DVA Card No.(Required)

DVA Card Colour(Required)

4.2 Your Medicare Details

Medicare Card(Required)

Yes

No

You will be required to upload a copy of the front and back of your medicare card at the end of this application.

Medicare Card No.(Required)

Number in front of your name on the Medicare Card(Required)

Medicare Card valid-to/expiry(Required)

e.g 06/2022

4.3 NDIS

Are you an NDIS participant?(Required)

Yes

No

NDIS Participant No.(Required)

Details about your NDIS plan(Required)

5. Assets and Income Information

Completing Steps 4 and 5 will assist us with determining your financial status so that we can provide you with draft fees and costs and answer any queries or concerns you may have.

5.1 Principal Home Information

Do you own your home?(Required)

Yes

No

Section 5.2 only applies to those that own their own homes

Home occupants(Required)

I live alone

I live with my spouse/partner

I live with a dependent child

I live with a carer (and have for more than 2 years)

I live with my immediate family (and have for more than 5 years)

Select all that apply

Are any of the above occupants eligible for an assessable pension/income support(Required)

Yes

No

Does not include a Carer Allowance

5.2 Principal Home Financial Information

Estimation of Value of your principal home

Total Value ($)(Required)

Less Mortgage ($)(Required)

Less Deferred Management Fees if in Retirement Living ($)(Required)

Less estimated selling costs ($)(Required)

Estimated Net Value ($)(Required)

5.3.2 Fortnightly income

For those which are not applicable, please insert a $0.

Australian Government Pension (Aged/DVA) ($)

Non-Australian Pension ($)

Superannuation ($)

Property Income (net) ($)

Other income ($)

Total Fortnightly Assessable Income ($)(Required)

5.4 Lodgement of Centrelink Assets and Income Assessment

Have you lodged a Centrelink Income and Assets Assessment? (SA485-1907/SA457-1907)(Required)

Yes

No

Date of Centrelink Income and Assets Assessment logement(Required)

Have you received the 'Residential aged care fees' letter from Centrelink?(Required)

Yes

No

If Yes, you will be required to upload a copy of the letter at the end of this application.

Are you intending to lodge a Centrelink Income and Assets Assessment(Required)

Yes

No

Please note

If you do not intend lodging a Centrelink Income and Assets Assessment you will be liable to pay the maximum means tested care fee on admission regardless of your financial status.

Proposed date of lodgement of Centrelink Income and Assets Assessment(Required)

6. Your Health Information

Completing this section will assist us with offering you placement at a Southern Cross Care Residential Home that reflects your care needs.

6.1 Aged Care Assessment (ACAT)

An ACAT assessment can also be called an Aged Care Client Record (ACCR) or a Support Plan.

Have you had an ACAT Assessment?(Required)

Yes

No

Please note

If ACAT Approval Code is not provided you may be charged the maximum fees until provided.

Date of ACAT Assessment(Required)

Do you have a copy of the Assessment?(Required)

Yes

No

If yes, you will be required to upload a copy at the end of this application. If you do NOT have a copy of the ACAT please provide the referral code for PERMANENT RESIDENTIAL APPROVAL. This code starts with the number 1 – followed by 11 numbers. e.g. 1-2345678905.

ACAT Referral Code

Please note if ACAT referral code is not provided you may be charged the maximum fees until provided.

6.2 Your current health status

Whilst the ACAT does provide health and medical information, if there have been changes to your health and wellbeing, then completing this section will further assist us in ensuring an offer of placement that reflects your care needs.

Have you had any new medical diagnoses since your ACAT Assessment?(Required)

Yes

No

Please record any new medical diagnoses:(Required)

6.2.1 Food and Refreshments needs

If no changes are required, please do not check any boxes. Please detail any changes in the text box below the check boxes.

Food and Refreshments Changes

Change of diet (e.g soft/pureed)

Has thickened drinks

Independent with eating/drinking

Needs supervision with eating/drinking

Needs assistance with eating/drinking

Uses eating/drinking aids

Specific diet (e.g diabetic, low fibre)

Uses a gastric (PEG tube)

Other (specify in below box)

Select all that apply

Details of Food and Refreshments Changes

Please provide additional details to any of the above changes that apply to you.

6.2.2 Personal Hygiene

If no changes are required, please do not check any boxes. Please detail any changes in the text box below the check boxes.

Personal Hygiene Changes

Washing/showering

Dressing/grooming

Independent with personal hygiene

Needs supervision with personal hygiene

Needs assistance with personal hygiene

Other (specify in below box)

Select all that apply

Details of Personal Hygiene Changes

Please provide additional details to any of the above changes that apply to you.

6.2.3 Continence

If no changes are required, please do not check any boxes. Please detail any changes in the text box below the check boxes.

Continence Changes

Urinary incontinence

Bowel incontinence

Uses continence aids/pads

Independent with toileting

Needs supervision with toileting

Needs assistance with toileting

Has long term catheter

Other (specify in below box)

Select all that apply

Details of Continence Changes

Please provide additional details to any of the above changes that apply to you.

6.2.4 Mobility

If no changes are required, please do not check any boxes. Please detail any changes in the text box below the check boxes.

Mobility Changes

Full mobility

Walks with aids (e.g cane, frame)

Uses a wheelchair

Bedridden

Independent but very slow

Needs supervision

Needs assistance

Other (specify in below box)

Select all that apply

Details of Mobility Changes

Please provide additional details to any of the above changes that apply to you.

6.2.5 Falls Risk

If no changes are required, please do not check any boxes. Please detail any changes in the text box below the check boxes.

Falls Risk Changes

History of past falls/injuries

Any recent falls/injuries

Frequency of falls

Other (specify in below box)

Select all that apply

Details of Falls Risk Changes

Please provide additional details to any of the above changes that apply to you.

6.2.6 Cognition and Behaviours

If no changes are required, please do not check any boxes. Please detail any changes in the text box below the check boxes.

Cognition and Behaviours Changes

Short-term memory problems

Long-term memory problems

Verbal aggressive behaviours

Physical aggressive behaviours

Confusion

Disorientation

Wandering

Other (specify in below box)

Select all that apply

Details of Cognition and Behaviours Changes

Please provide additional details to any of the above changes that apply to you.

6.2.7 Mental Health

If no changes are required, please do not check any boxes. Please detail any changes in the text box below the check boxes.

Mental Health Changes

Anxiety

Depression

Delirium

Paranoia

Other (specify in below box)

Select all that apply

Details of Mental Health Changes

Please provide additional details to any of the above changes that apply to you.

6.2.8 Medication Management

If no changes are required, please do not check any boxes. Please detail any changes in the text box below the check boxes.

Medication Changes

Independent with taking own medication

Needs supervision

Needs full assistance

Needs medication to be crushed

Resistant/refuses to take medication

Is on daily injections

Is on periodic injections

Other (specify in below box)

Select all that apply

Details of Medication Changes

Please provide additional details to any of the above changes that apply to you.

6.2.9 Other specific care/clinical needs or concerns

Any other specific care/clinical needs or concerns?(Required)

Yes

No

Other specific care/clinical needs or concerns

7. Your Wellness & Lifestyle Information

This section is for you to let us know about what you like to do to enjoy yourself and relax. It’s to help us get to know you a bit better and to help us consider what Leisure and Lifestyle activities you might prefer.

Interests

Outside activities; gardening, bird watching, walks

Socialising with others, social clubs, special interest clubs

Day trips, short excursions

Reading and writing, alone or with others

Music and/or dancing

Gentle exercise, seated yoga, pilates, resistance training

Art: enjoying, discussing or partaking

Food, cooking, drinking or just trying new dishes

Other preferences or special interest hobbies

Feel free to add details or other options here

8. Attachments

Please upload all of the following attachments, or email copies of necessary documents to enquiries@scctas.org.au

Medicare card scan front

Accepted file types: jpg, pdf, png, heic, Max. file size: 5 MB.

Medicare card scan back

Accepted file types: jpg, pdf, png, heic, Max. file size: 5 MB.

Centrelink Aged Care Fees Letter and the Assets and Income Summary Statement

Accepted file types: jpg, pdf, png, heic, Max. file size: 5 MB.

Section 5.4

ACAT Assessment

Accepted file types: jpg, pdf, png, heic, Max. file size: 5 MB.

Section 6.1. Can also be referred to as an Aged Care Client Record (ACCR) or a Support Plan.

Any other applicable documents

Accepted file types: jpg, pdf, png, heic, Max. file size: 5 MB.

Eg copies of Power of Attorney or Guardianship approvals.

Offer of Placement

If an offer is made for placement:

we will contact you to view the available accommodation and request you attend the home within 24 hours
if placement is accepted admission will generally need to occur within 48-72 hours from time of offer.

Do you have any other information that you would like to provide, at this time, with your application?

Declaration

Name of person making declaration(Required)

First Last

Relationship of person making declaration to applicant(Required)

Please read and acknowledge the below declaration.(Required)

By checking this box, I sincerely declare that all of the information in this application is true to the best of my knowledge. It is in no way false, inaccurate or misleading, or intended to be false, inaccurate or misleading. I agree that if incorrect fees or charges are levied as a result of information provided in this form then Southern Cross Care may levy the correct charges from the Applicant’s date of entry to a Southern Cross Care Residential Care Home.

I acknowledge the declaration

Digital Application Form for permanent accommodation & care

Step-by-step guide to your application

Accompanying Documents

Permanent accommodation & care application form

Thank you for considering Southern Cross Care (Tasmania) Inc. as your new home.

Privacy of your personal information held by Southern Cross Care

1. Southern Cross Care Residential Homes and Locations

Residential home preferences

2. Time Frame for Your Move to Residential Care

3. Personal Information

3.1 Your Personal Details

3.2 Marital Status

3.3 Your Cultural Information

3.4 Your Current Location

3.5 Your Contact Information

3.6 Your Nominated Representative(s)

3.6.1 Primary representative

3.6.2 Secondary representative

3.7 Nominated Family Spokesperson

3.8 Current General Practitioner

4. Pension and Medicare Information

4.1 Your Pension Details

4.2 Your Medicare Details

4.3 NDIS

5. Assets and Income Information

5.1 Principal Home Information

5.2 Principal Home Financial Information

5.3 Assessable Assets and Income

5.3.1 Assessable Assets

5.3.2 Fortnightly income

5.4 Lodgement of Centrelink Assets and Income Assessment

6. Your Health Information

6.1 Aged Care Assessment (ACAT)

6.2 Your current health status

6.2.1 Food and Refreshments needs

6.2.2 Personal Hygiene

6.2.3 Continence

6.2.4 Mobility

6.2.5 Falls Risk

6.2.6 Cognition and Behaviours

6.2.7 Mental Health

6.2.8 Medication Management

6.2.9 Other specific care/clinical needs or concerns

7. Your Wellness & Lifestyle Information

8. Attachments

Offer of Placement

Declaration

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How can we help you?