Suburb: Post code: Council: Postal (if diff): Telephone: (h) (w) (m) Email: Living arrangements: living alone living with others living with family (includes spouse) Accommodation setting: own home/purchasing private rental independent living unit public rental supported accommodation other Country of Birth: Main Language spoken at home: Indigenous status: Not indigenous Aboriginal Torres Strait Islander Prefer not to say Department of Veterans Affairs card status: Not a DVA card holder Gold Card White Card Other DVA card Employment Status: Full time Part time Casual Seasonal Not in paid employment Primary Diagnosis/Disability: Does the client/care recipient have dementia? Yes suspected, but not diagnosed No Comments: Does the client/care recipient have an NDIS plan? Yes No GP Details Dr: Address: Ph: CARING ROLE ASSESSMENT: Time spent caring in a typical week: Under 20 hrs 20 – 40 hrs over 40 hrs In a typical week, what does the carer do for the CR? Personal care (eg. showering and dressing) Housework Transport Managing finances Meal Preparation Shopping Feeding (assisting client/care recipient to eat) Continence management Transfers (assisting with getting in/out of chairs/cars etc) Medication administration Emotional support Daily routine support Behaviour support/management Advocacy Liaison with agencies Phone contact with the client/care recipient ALL OF THE ABOVE Does the have a disability? Does the carer have any of the following: Difficulties or stress relating to their caring role Please specify: Health conditions of their own Please specify: Goals relating to their caring role or access of support services Please specify: Any details not recorded elsewhere Comments: Does the carer drive? What is the main reason for your registering as a carer? To access respite in case of emergency To access respite now To make use of Carer Support’s groups and activities
Shopping Managing finances ALL OF THE ABOVE Does the CLIENT/CARE RECIPIENT have any of the following? Risk of Wandering Aggressive behaviour (verbal) Aggressive behaviour (physical) Restlessness or agitation Constant supervision required Emotional support required Seizures Chest pains Disorientation Sleep disturbance Hearing impairment Vision impairment Diabetes, (please select): insulin tablets diet Depressive symptoms Memory problems or confusion Comments: Difficulty communicating Comments: Mental illness, diagnosed? Yes No Comments: Challenging behaviour Comments (please include details of specific triggers and behaviour management strategies): Allergies Please specify: Hazards in the home Please specify: Indoor smoker(s) Outdoor smoker(s) Dog(s) Cat(s) Support worker preference, please select: Male worker Female worker Please specify any requirements: OTHER SERVICES FOR CARER/CLIENT/CARE RECIPIENT: Has the client/care recipient had any assessments? ACAT, approved for: LOW CARE HIGH CARE Home Care Package: 1 Level 3 Level 2 Level 4 Regional Assessment Team (RAS) MAC referral code: Service Type: NDIS Assessment Disability SA Assessment Date Assessed (if known): / / Awaiting assessment – Assessment date (if known): / / Comments: Is the carer or client/care recipient currently receiving any other services, including services funded by Domiciliary Care, Disability SA, NDIS or a Home Care package?: No other services Veterans’ Home Care Commonwealth Home Support Service Home Care Package, Council Services NDIS Plan Disability SA Palliative Care Community Mental Health Services Clinical Mental Health Services Other services Please provide details about type of assistance, who is providing it, how often etc. Does the carer or client/care recipient receive any other informal supports from family/friends etc? Please post completed form (or drop in) to Carer Support, 770 South Road, Glandore SA 5037 OR scan it, and send it in an email to Phone: 1800 052 222 or (08) 8433 9555 Fax: (08) 8297 4086 Office Use only: