Home support services help people to remain in their own homes for as long as possible.

This self-assessment form will take approximately 15-20 minutes to complete and it will get you thinking about what your needs are, considering what daily activities you might need some extra help with. For us it provides information so together we can develop a plan that will give you the very best level of assistance so you can live well and remain at home for as long as possible.

At the very end of the form we do ask for some specific information like Medicare numbers, health fund details, pension details, doctors details, ambulance numbers and next of kin details. This is not required information but it may save you time in the long run.

Alternatively, you can download a copy of the form here and mail it too PO Box 155, Glen Osmond SA 5064.

If completing on behalf of another person, please indicate relationship to person who requires assistance and try to reflect their responses.

About you:

  I'm OK at the moment I could do with a bit of help I have a bit of help, but need a bit more I have enough help I'm not sure

About your health:

  I'm OK at the moment I could do with a bit of help I have a bit of help, but need a bit more I have enough help I'm not sure

About your home:

  I'm OK at the moment I could do with a bit of help I have a bit of help, but need a bit more I have enough help I'm not sure

If there is anything you would like more information about, please write in the box below.

For example you may like to explore ways to assist with maintaining or improving your sense of health and wellbeing, perhaps your diet and exercise needs, or opportunities to learn about and best manage a health problem. If you would like to talk with a Home Care Coordinator, you are welcome to call 1800 852 772, at any time.

Other Details

You do not have to complete this information now but it will save time when our Home Support Services team come out to visit you.

Doctor:

Significant Contact 1:

Significant Contact 2: