To provide even basic Aged Care advice we require the information requested in this form to be completed. All data is retained as Private & Confidential
Client's First Name
Client's Last Name
Centrelink Reference Number / DVA File Number
Pension Type
Self Funded (likely over Assets or Income)
Not Eligible (Residency or other)
Age Pension
Blind Pension
Disability Pension
DVA Service
DVA Disability TPI
No elements found. Consider changing the search query.
List is empty.
Current Pension (per fortnight)
$
Health Status
Excellent
Good
Average
Poor
No elements found. Consider changing the search query.
List is empty.
Has Dementia?
Yes
No
Current Location
Home
Hospital
Facility
Respite
Elsewhere
No elements found. Consider changing the search query.
List is empty.
Primary Client's Date of Birth
Gender
Male
Female
Is the Will Current?
Yes
No
Do you have a Power of Attorney?**
Yes
No
**If YES, Please email a copy of the Power of Attorney document to
[email protected]
Power of Attorney's Name
Power of Attorney's relationship to the client
Client's Type of Care Sought
Residential Aged Care
Stay At Home
Retirement Village
Land Lease Community
No elements found. Consider changing the search query.
List is empty.
Aged Care Facility Name
Date of Permanent Aged Care Entry (if entered into care)
Quoted / Estimated RAD Amount
$
Quoted Additional / Extra Service Fee per day (Not the $58.98 basic daily fee)
Amount of RAD paid (if applicable)
$
RV / LLC Facility Name
With Home Care Package?
Yes
No
Date Home Care Package Commenced
Basic Daily Fee of Home Care
Level 1
Level 2
Level 3
Level 4
No elements found. Consider changing the search query.
List is empty.
Purchase Price
$
Date Purchased
Deferred Management Fee
Exit Entitlement
General Service Charge / Site Fees
Relationship Status
*
Single
Couple
Couple Illness Separated
Partner's First Name
Partner's Last Name
Partner Pension Type
Self Funded (likely over Assets or Income)
Not Eligible (Residency or other)
Age Pension
Blind Pension
Disability Pension
DVA Service
DVA Disability TPI
No elements found. Consider changing the search query.
List is empty.
Partner's Current Pension (per fortnight)
$
Partner's Health Status
Excellent
Good
Average
Poor
No elements found. Consider changing the search query.
List is empty.
Does Partner have Dementia?
Yes
No
Partner Current Location
Home
Hospital
Facility
Respite
Elsewhere
No elements found. Consider changing the search query.
List is empty.
Partner's Date of Birth
Partner's Gender
Male
Female
Is partner's Will current?
Yes
No
Does partner have Power of Attorney?**
Yes
No
**If YES, Please email a copy of the Power of Attorney document to
[email protected]
Name of Partner's Power of Attorney
Partner's Relationship to Power of Attorney
Partner's Type of Care Sought
Residential Aged Care
Stay At Home
Retirement Village
Land Lease Community
No elements found. Consider changing the search query.
List is empty.
Partner's Aged Care Facility Name
Partner's Date of Entry (If entered into care)
Partner's Estimated RAD Amount
$
Partner's Quoted Additional / Extra Service Fee per day (Not the $58.98 basic daily fee)
Partner's Amount of RAD Paid (if applicable)
$
Partner RV / LLC Facility Name
Partner With Home Care Package?
Yes
No
Partner Date Home Care Package Commenced
Partner Basic Daily Fee of Home Care
Level 1
Level 2
Level 3
Level 4
No elements found. Consider changing the search query.
List is empty.
Partner Purchase Price
$
Partner Date Purchased
Partner Deferred Management Fee
Partner Exit Entitlement
Partner General Service Charge / Site Fees
HOME
Home Address
Home Value
$
Is there a protected person living in the home (other than spouse)?
Yes
No
If Home is Rented
Rental Amount (per week)
$
PERSONAL ASSETS
Contents, Collections, and Artworks (please put details and amount)
Vehicles (please put details and amount)
Funeral Bond/Prepaid Funeral (please put details and amount)
Gift or Any Additional Assets (please put details and amount)
INVESTMENTS
Bank Account 1 (bank name and amount)
Bank Account 2 (bank name and amount)
Term Deposit Account (bank name and amount)
Shares (please put details and amount)
Investment Property (if any)
Other Investments
INCOME
Any Income Received (please put details and amount)
ACCOUNT BASED PENSION
Description/Name
Asset Value
Payment Received (please include if per month or per fortnight)
Purchase Date
DEFINED BENEFIT SUPERANNUATION
Description/Name
Payment Received (please include if per month or per fortnight)
ADDITIONAL INFORMATION/QUESTIONS
Are there any questions in particular you would like answers to in the meeting?
How can we best add value to your situation?
Contact Email
*