New Client Registration

Care recipient information

Full Name *

Preferred Name

Date of Birth *

Gender *

Marital Status *

Usual home address *

Where is the care recipient currently? *

Pension Number *

Medicare card number and position on card

Medicare Expiry Date

Aboriginal and/or Torres Strait Islander origin? *

Current General Practitioner details

Practice Name *

Doctor Name *

Address *

Phone Number *

Representative information

Primay contact

Full name *

Relationship to care recipient *

Best contact number(s) *

Email address *

Postal address *

How did you hear about HAAA? *

Contact 2 (if applicable)

Full name

Relationship to care recipient

Best contact number(s)

Email address

Postal address

Additional contacts

Social workers, case managers etc.

Details to assist us with the placement

My Aged Care Residential Permanent Referral code (Example 1-1111111111111)

My Aged Care Respite Referral code (Example 1-1111111111111)

Summary of main care and health concerns

What is the preferred geographic region for the placement to occur?

Summary of income

Does care recipient receive a pension / part pension / overseas pension / super / annuity, any rental income etc If so, how much? It is important for HAAA to be provided with this information so we can determine the affordability of the residential care options we can present to you. (Approximate amounts are OK for now)

Summary of assets

Does care recipient own a home or investment properties, bank accounts, shares, term deposits, superannuation etc If so, How much? It is important for HAAA to be provided with this information so we can determine the affordability of the residential care options we can present to you. (Approximate amounts are OK for now)

Summary of ideal placement and / or any other information you think we should know regarding the placement

Documents required for placement

Please upload as many of the below documents as you can in PDF format. If you haven’t got all of these documents now, that’s OK. You can forward to your placement consultant as soon as you can.

Support Plan / Referral codes