Before proceeding, please make sure the person lives in Care in Motion's delivery regions: Yorke Peninsula, Copper Coast, Barunga West, Clare Valley, Burra, Balaklava, Mallala, Hamley Bridge.
This form is used to refer an older person living in a Residential Aged Care Facility or living in their own home and approved for or receiving a Support at Home Package (referred to as the Care Recipient) to the Aged Care Volunteer Visitors Scheme (ACVVS). This form is to be completed by the aged care provider representative, ACVVS auspice coordinator, the Care Recipient, or their representative. The Aged Care Volunteer Visitors Scheme is funded by the Australian Government.
More information about the scheme can be found here:
https://www.health.gov.au/our-work/aged-care-volunteer-visitors-scheme-acvvs

For this referral to be lodged, consent must be given by either the care recipient themselves or their Next of Kin.

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Consent has been given by (Full Name):

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Relationship to Care Recipient
If submitting on own behalf, write "self-referral"

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Referrer Details
Your details, as the person submitting this referral

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Relationship to Care Recipient
E.g next of kin, Lifestyle Coordinator, Home Care Provider, Friend

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Phone Number

Care Recipient Home or Residential Aged Care Home Details
Details of the Home or Residential Aged Care Home where the Care Recipient resides.

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Does the Care Recipient live at own home or at a Residential Aged Care Home?

Please provide the appropriate details below for either the Care Recipient's Support at Home (previously called Home Care Package) OR their Residential Aged Care Home.
Leave any non-relevant sections blank.

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Care Recipient's Support at Home Provider
Note, this can be the provider they currently have, or the one they are approved for.

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Care Recipient's Home Address

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What is the Care Recipient's Phone Number (no spaces please)

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Please provide an Emergency Contact (Support at Home clients only)

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Does the Care Recipient have any pets on site (dog or cat etc)

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Name of Residential Aged Care Home (RACH)

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RACH Address (street address)

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Residential Aged Care Home Contact Person

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Residential Aged Care Home Phone Number

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Care Recipient Details
The person who would benefit from the Aged Care Volunteer Visitors Scheme.

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Reason for Referral
E.g. lack of regular visitation, family lives interstate/overseas, feelings of loneliness/depression/isolation

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Date of Birth

Date

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Gender Identity

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Preferred Pronouns
(she/her, he/him, they/them)

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Country of Origin

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Preferred Language(s)

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Background (Work, Family, Culture)

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Hobbies and Interests

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Can you provide any extra details about their hobbies or interests? What activities might they enjoy participating in with their community visitor?

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Current Visitors and Relationships

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During lock downs (e.g. COVID 19 or Gastro) if face-to-face visits are postponed, we offer virtual visits. Please indicate what types of visits the older person would prefer to participate in:

Special Needs Groups
The following information is important as it will be used to better direct the care recipient to services and is requested by the Department of Health. The information will be kept in the strictest of confidence.

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Does the care recipient identify as being from any of the following special needs groups (as specified under the Aged Care Act 1997)? (Required.)

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If you have selected "None of the above", please provide a general comment about the Care Recipients support needs:

Health Status of Care Recipient
It's important that we are aware of any health or medical concerns that may impact on visits. This information is important to ensuring a suitable match.

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Please describe the Care Recipient's eyesight (Required.)

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Please describe the Care Recipient's hearing (Required.)

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Please describe the Care Recipient's speech (Required.)

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Please describe the Care Recipient's physical health/mobility
E.g. uses a walker/wheelchair, can't stand for long periods, fall-risk (Required.)

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Does the Care Recipient have any challenging behaviours we should be aware of?
E.g. past incidents, inappropriate comments, aggression (Required.)

Preferences for Visitor
The Care Recipient's preferences for a visitor will be taken into account when finding a suitable volunteer. We cannot guarantee that all preferences will be met.

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Preferred Gender

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Preferred Age

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Language or Cultural Preference

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Religious Preference

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Would the Care Recipient like a visitor who is from the LGBTQIA+ Community? 

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Any other preferences?

Other Comments

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Please share any other comments or information that may be relevant

Referral Submission
Thank you for taking the time to complete this referral. By clicking submit you will lodge this referral for the Aged Care Volunteer Visitors Scheme to Care in Motion (Community Care and Transport Inc.) This recipient will be placed on our waitlist. A representative from Care in Motion will be in contact regarding the outcome of your referral, and regarding the next steps in arranging a Volunteer Visitor for the Care Recipient.
In the meantime if you have any questions please reach out.
acvvs@careinmotion.org.au
https://careinmotion.org.au/

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