Aged Care Waiting List - Woolgoolga Retirement Village

Residential Aged Care Waiting List Application

Thank you for your interest in Woolgoolga District Retirement Village. This form is to be completed for inclusion on our Independent Living Unit Waiting List. The information provided on this form will be maintained in a highly confidential manner, with only authorised staff provided access.

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CARE RECIPIENT DETAILS (The details of the person requiring residential care)

Type of Care required

Permanent
Respite

Name

First

Last

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Preferred Name (s)

Date of Birth

Current Residential Address

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Town/Suburb

State

Postcode

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Home Telephone

Mobile

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Would the Care Recipient like to be contacted regarding this application?

Preferred Method of Contact

Phone
Email
Other

NOMINATED PERSON DETAILS

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Relationship to Applicant

Authorised Representative?

Name

First

Last

Residential Address

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Town/ Suburb

State

Postcode

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Home Telephone

Mobile

OTHER INFORMATION (Relating to the person requiring residential care)

Do you have a current Aged Care Client Record or Support Plan Provided by the (ACAT)?

Referral Codes

Are you in receipt of NDIS services OR do you have NDIS approval?

Do you have a letter from Centrelink/DVA confirming your financial status following completion of the Permanent Residential Aged Care Request for a Combined Assets & Income Assessment?

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Medicare Number

Expiry Date

No. on Card

Residential Aged Care Waiting List Application

CARE RECIPIENT DETAILS (The details of the person requiring residential care)

NOMINATED PERSON DETAILS

OTHER INFORMATION (Relating to the person requiring residential care)

About

How can we help?

Get in touch

Residential Aged Care Waiting List Application

CARE RECIPIENT DETAILS (The details of the person requiring residential care)

NOMINATED PERSON DETAILS

OTHER INFORMATION (Relating to the person requiring residential care)

About

How can we help?

Get in touch

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