Form

Enquiry Form

If you would like more information about our personalised one on one service and to assist you in finding the right home for your loved one, please complete the enquiry form below.

Alternatively you can contact us on:
1300 442 383
Please note 'Client' refers to the person requiring aged care.
'Contact' refers to the family member supporting the client with the move to aged care.

Client First Name*

Client Last Name*

Client Date of Birth

Client Gender

Languages

ACAS Number

(Required for clinical approval - if unknown, please enter TBC)

Accommodation Type*

(eg., respite or permanent)

Preferred Facility Location

(eg., suburb or region)

Medical History

(If known)

Care Needs

(MSU, level of care required)

Notes

(Reason for enquiry, any other detail to assist)

Home Care Provider*

(If known, otherwise select "Other")

Home Care Provider Contact Name*

(If known, or enter NA)

Home Care Provider Contact Email

(If known, or enter NA)

Home Care Provider Contact Number

(If known, or enter NA)

Which facilities (aged care homes) have you approached so far?*

(List the homes you have approached prior to engaging with Care Guidance.)

Have you toured these facilities?*

(If you have toured these facilities please tick yes, otherwise no.)

Yes

Extra Information*

(Please tick all that apply)

Have you had the discussion with all family members regarding the aged care placement?

Are you the only person acting on behalf of the client?

Have you engaged with any other Aged Care Placement Agency?

Is the client currently receiving an HCP (Home Care Package)?

Is the client in agreement for aged care?

Contact First name*

Contact Last name*

Client relationship

Contact Phone number*

(If no phone number is available, please contact us on 1300 442 383)

Contact Email

(If no email is available, please contact us on 1300 442 383)