Western Australia Companion Card Application Form
Transcript of Western Australia Companion Card Application Form
Eligibility Criteria
Companion Card Application Form Western Australia
There are 4 requirements to be eligible for a Companion Card:
You live in Western Australia; and
Youhaveasignificantdisability,whichmayincludeissuesrelatedtoageingandpsychiatric illness; and
Duetotheimpactofyourdisabilityyouwouldbeunabletoparticipateatmostcommunity venuesoractivitieswithoutattendantcaresupport; and
Yourneedforthislevelofsupportwillbelife-long.
TheCompanionCardisnotissuedtopeoplewhoonlyrequirereassurance,social companyorencouragement. SometimesapersonmayrequireacompanionbutnotbeeligibletoreceiveaCompanion Card.Examplesincludeapersonwhois: -experiencingatemporarydisability -unlikelytorequirelifelongattendantcaresupport -affectedbytheinaccessibilityofaparticularvenue
Yourserviceprovider,healthprofessional,legalguardianoragentmayassistyoutocompletethisform.Pleaseensureyoucompleteallrelevantsectionsasincompleteapplicationscannotbeprocessed.
Step 1. CompleteItems1–4oftheapplicationform.
Step 2. Gettwoidenticalhighqualitycolourpassport-sizedphotographs (seepage2fordetailsofacceptablephotos)
Step 3. Takeyourformandphotosforverificationbyeitheraspecifiedserviceproviderat Item5oraspecifiedhealthprofessionalatItem6.
Step 4. Attachyourphotographstothetopofpage10withapaperclip.
Step 5. CompleteandsigntheapplicantstatementatItem7.
Step 6. Returnthecompletedapplicationformandverified photosto: CompanionCardApplications ReplyPaid1595 OSBORNEPARKBCWA6916
How to Apply
Attendantcaresupportincludessignificantassistancewithmobility,communication,selfcare,orlearning,planninganddecisionmaking,wheretheuseofaids,equipmentoralternativestrategiesdoesnotenablethepersontocarryoutthesetasksindependently.
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Not all people with a disability are eligible for a Companion Card:
PhotographsYoumustincludetwocurrentidenticalcolourpassport-sizedphotographsshowingyourheadandtopofshoulderswithyourapplication. YourphotographwillbeprintedonyourCompanionCard.
ThebackofEACHphotographmustinclude: thenameofthepersoninthephotograph;and thesignatureofthesameserviceproviderorhealthprofessionalwhosignedeither Item5or6ofyourapplicationform.
Acceptable PhotosThefollowingguidelineswillhelpyouprovidesuitablephotographs,sothatyourapplicationisnotdelayedbyhavingtosubmitnewphotographsintherequiredformat.
Colourphotosonly(notblackandwhite) Printedongoodqualityglossphotopaper Nograiny,pixilatedorblurryimages
Assessment of Applications
x x x 335-40mm
45-50m
m
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For more information, please contact the Companion Card WA Office:Tel: 1800 617 337TTY: 9443 3107Email: [email protected]: www.wa.companioncard.asn.au
Pleaseallowapproximately20workingdaysforprocessing(mayincreaseduringpeakperiods).TheCompanionCardprogramwillassesseachapplicationagainstallofthefoureligibilitycriteriafortheprogram. Ifmoreinformationisneededtodetermineeligibility,theWACompanionCardprogrammay:
contacttheapplicant(orlegalguardian/agent)toaskforadditionalinformation. followupwiththeserviceproviderorhealthprofessionalwhoverifiedtheapplication. requestinformationfromrelevantgovernmentdepartmentsorserviceprovidersto assistwiththeassessmentofyourapplication.
PleasenotethatcompletionofanapplicationformdoesnotguaranteeaCompanionCardwillbeissued.
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Title:
Item 1. Applicant details
TheCompanionCardwillonlybeissuedinthenameofthepersonwiththedisability. Oneapplicationmustbecompletedperapplicant.
FirstName(asitisonofficialdocumentationsuchasabirthcertificate):
Surname:
DateofBirth:ddmmyyyy
Mr Mrs Ms Miss Other
Age:
MaleFemaleGender:
Email:
Telephonenumber:
TelephoneTypewriter/(TTY)ifapplicable:
Yes NoIsyourdisabilitypermanent?
IfyourdisabilityisnotpermanentyoudonotmeettherequirementstoreceiveaCompanionCard–donotproceed.Contactthefreecallnumber1800617337forfurtherinformation.
ResidentialAddress:
Suburb:
State: Postcode:
PostalAddress(ifdifferentfromabove):
Suburb:
State: Postcode:
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Item 2. Describing your disability
Whatisyourprimarydiagnosis?
Doyouhaveanyothermedicalconditionsthatarerelevanttoyourneedforattendantcaresupporttoparticipateatmostcommunityvenuesoractivities?
Item 3. Disability specific information
TobeeligibleforaCompanionCardyoumustdemonstratewhyyourdisabilityorconditionmakesyoupermanentlyunabletoparticipateatmostcommunityvenuesandactivitieswithoutsignificantattendantcaresupport.
Do you require attendant care support with any of the following in order to take part in community events and activities?
Mobility(thisisaboutyourabilitytomovearound,forexample,yourneedforattendant caresupporttonavigateyourwheelchair,assistyoutoaccessyourseatorothervenuefacilities.)
Yes No
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IfYes,pleaseprovidespecificexamplesaboutyourmobilityrequirements.Atcommunityactivities,Irequireattendantcaresupportto:
Communication(thisisaboutunderstandingandbeingunderstoodbyothers,forexample, yourneedforattendantcaresupporttopurchaseticketsoraccessyourseat.
Yes No
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IfYes,pleaseprovidespecificexamplesaboutyourcommunicationrequirements.Atcommunityactivities,Irequireattendantsupportto:
Learning, planning and decision making(thisisaboutyourabilitytoplanandcarryout anactivityinthecommunityindependently,forexample,yourneedforattendantcare supporttoassistwithhandlingmoney,andguidingyoutoknowwhereandwhattodoata particularevent).
Additional comments Isthereadditionalinformationthatyouwouldliketoprovidetosupportyourapplication foraCompanionCard?Forexample,detailsofservicesandsupportsyoureceive(respite, therapy,localareacoordination)ordetailsofformalassessments.
Self care(thisisaboutdailypersonalcaretaskswhereforexampleyoumayrequiresupport fromacompaniontodressortoilet.)
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IfYes,pleaseprovidespecificexamplesaboutyourselfcarerequirements.Atcommunityactivities,Irequireattendantsupportto:
Yes No
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IfYes,pleaseprovidespecificexamplesaboutyourlearning,planninganddecisionmakingrequirements.Atcommunityactivities,Irequireattendantsupportto:
Yes No
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Do you currently receive any of the eight specific services or supports listed below?
Ifyouareunsure-checkwithyourLACorServiceProvider
Yes,pleaseindicatebelow
No,pleasegostraighttoItem6onpage8.YoudonotneedtocompleteItem5.
(youcantickmorethanonebox)
AccommodationSupportservice,fundedorprovidedbytheDisabilityServicesCommission
IntensiveFamilySupportpackage,fundedorprovidedbytheDisabilityServicesCommission
AlternativestoEmploymentprogram,fundedorprovidedbytheDisabilityServicesCommission
SupportedAccommodationAssistanceProgram,fundedorprovidedbytheOfficeofMentalHealth
ResidentialAgedCareServices,fundedorprovidedbytheAustralianGovernment
ExtendedAgedCareatHomepackage,fundedorprovidedbytheAustralianGovernment
CommunityAgedCarepackage,fundedorprovidedbytheAustralianGovernment
Veteran’sAffairsAttendantAllowance,fundedorprovidedbytheAustralianGovernment
Item 4. Service & Supports
Ifyouhaveindicatedyoureceiveaserviceorsupport,pleasetakethisformtogetherwithtwoidenticalcolourpassport-sizedphotographstoyourServiceProviderorLACtocompleteItem5.
To be completed by Service Provider, or LAC: Service and Supports verification Pleaseverifythattheapplicantcurrentlyreceivestheselectedservices orsupportslistedatItem4.
Service provider or LAC contact details
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Yes No
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Name:
Position:
Employer/OrganisationName:
Address:
TelephoneNumber:
Email:
Suburb: Postcode:
Photographs Pleaseverifythatbothpassportsizedphotographssuppliedareoftheapplicant,bywritingon thebackofthephoto’s: thisisaphotoof(insertthenameofthepersoninthephotograph) yoursignature Service Provider or LAC Declaration Iconfirmthatmysignaturebelowverifies all of the following(pleasetick):
IhavereadandunderstandtheCompanionCardeligibilitycriteria; Ihavereadalloftheinformationcontainedinthisformandverifythatitiscorrecttothe bestofmyknowledge;
Iamnottheapplicantoranimmediatefamilymemberoftheapplicant;
IagreetoofferallreasonableinformationtoassisttheCompanionCardprogramtodetermine theapplicant’seligibility;
Iunderstandthatitisanoffensetoprovidefalseormisleadinginformationinthisapplication.
Applicant Note: If you receive one of the eight specific services and your service provider has completed this section, PLEASE GO TO ITEM 7. You do not need to complete ITEM 6.
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Date: //
Signature: OrganisationStamp(ifavailable):
Item 5. Service Provider or LAC details
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Item 6. Health Professional Details
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Yes No
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Applicantnote:ThisitemisonlytobecompletedifyoudonotreceiveaserviceorsupportaslistedatItem4 Takethisformtogetherwithtwoidenticalcolourpassport-sizedphotographstooneoftheHealthProfessionalslistedbelowforverification.
To be completed by Health Professional.
PleaseindicatewhichHealthProfessionalcategoryappliestoyou:
RegisteredMedicalPractitioner
Registered Nurse
RegisteredPhysiotherapist
RegisteredPsychologist
QualifiedOccupationalTherapisteligibleformembershipwithOccupationalTherapyAustralia
QualifiedSocialWorkereligibleformembershipwiththeAustralianAssociationofSocialWorkers
QualifiedSpeechPathologisteligibleforpracticingmembershipwithSpeechPathologyAustralia Doestheapplicantrequirelifelongattendantcaresupporttoparticipateatmost communityvenuesandactivities?(Attendantcaresupportincludessignificantassistance withmobility,communication,selfcare,orlearning,planninganddecisionmaking,wherethe useofaids,equipmentoralternativestratgiesdoesnotenablethepersontocarryoutthese tasksindependently)
Iftheneedforattendantcaresupportisnotpermanent,theapplicantisnoteligibletoreceiveaCompanionCard. Pleaseprovidedetailsconfirmingtheapplicant’slifelongneedforattendantcaresupportout inthecommunityinthearea’sof:mobility,communication,self-careorlearning,planningand decisionmaking.
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D Pleaseverifythatbothpassportsizedphotographssuppliedareoftheapplicant, bywritingonthebackofthephoto’s: thisisaphotoof(insertthenameofthepersoninthephotograph) yoursignature
HealthProfessionalcontactdetails
Pleaseprovideyourcontactdetailsbelow:
Name:
Position:
EmployerofBusinessName:
Address:
DaytimeContactNumber(s):
Email:
Health Professional Declaration
Iconfirmthatmysignaturebelowverifiesallofthefollowing:
IhavereadandunderstandtheCompanionCardeligibilitycriteria;
Ihavereadalloftheinformationcontainedinthisformandverifythatitiscorrecttothebest ofmyknowledge;
Iamnottheapplicantoranimmediatefamilymemberoftheapplicant;
IagreetoofferallreasonableinformationtoassisttheCompanionCardprogramtodetermine theapplicant’seligibility;
Iunderstandthatitisanoffensetoprovidefalseormisleadinginformationinthisapplication.
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Date: //
Signature: Professionalregistrationnumber/membershipnumber/stamp:
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Item 7. Applicant Statement
Thisitemistobecompletedbytheapplicantortheirlegalguardian/agent.
Iconfirmthatmysignatureonthefollowingpageverifiesthat:
IauthorisetheCompanionCardprogramtoverifytheinformationcontainedin thisformandtoobtainfurtherinformationrelatingtomyeligibilityforaCompanion Card.Thismayincluderequestinginformationheldindatabasesbygovernment departments,organisationsandagencies;
IagreethatHealthProfessionalsorServiceProvidersmaydiscloseinformation aboutmetotheCompanionCardprogramtoassistwiththeassessmentofmy application;
IhaveapermanentdisabilityandIwillalwaysrequireattendantcaretypesupport toparticipateatmostcommunityvenuesandactivities;
IwilladvisetheCompanionCardprogramofanychangesinmycircumstances thatmayaffectmyeligibilitytoholdacard;
Icertifythattheinformationinthisapplicationiscorrect;andIunderstandand acceptthecardholderTermsandConditions.
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Attachphotohere
45mm
35mm
Affix verified photographs here using a paper clip or fold back clip.Do NOT use tape, staples, glue or pins
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You MUST provide one of the following signatures: ApplicantSignature(forapplicantsover18yearsofage)
OR
LegalGuardian/AgentSignature
Date://
Date://
LegalGuardian/AgentName(andrelationshiptotheapplicant)
Telephonenumber: TelephoneTypewriter/TTY(ifapplicable):
IconsenttoparticipatinginmediaopportunitiesandevaluationoftheCompanionCardprogram.
Yes No
Person who completed this form (if different from above)
Name(andrelationshiptotheapplicant)
Telephonenumber:
Privacy StatementInaccordancewithNationalPrivacyPrinciple(NPP04:DataSecurity),informationcontainedintheapplicationformwillnotbedisclosedtoanyotherorganisation:www.privacy.gov.au
Pleaseensureyoucompleteallrelevantsectionsasincompleteapplicationscannotbeprocessed.
Items1-4havebeencompletedbyyouoryourlegalGuardian/Agent.
YourapplicationformhasbeenverifiedbyeitheraspecifiedserviceprovideratItem5 oraspecifiedhealthprofessionalatItem6.
Thesamehealthprofessional/serviceproviderhasverifiedandsignedthebackofyour passportsizedphotographs.
Yourphotographsareattachedwithapapercliptothetopofpage10.
Item7hasbeencompletedandsignedbytheapplicantorlegalGuardian/Agent.
Applicant Checklist
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Please return the completed application form to: Companion Card ApplicationsReply Paid 1595OSBORNE PARK BC 6916
Companion Card Program WAUnit1,59WaltersDrive,OsbornePark.Replypaidpost:POBox1595, OsborneParkBCWA6916.Tel:1800617337,TTY:94433107,Fax:92425044Web:www.wa.companioncard.asn.auEmail:[email protected]
Applicant Note:
Allowapproximately20workingdaysforprocessing(mayincreaseduringpeakperiods).
CompletionofanapplicationformdoesnotguaranteeaCompanionCardwillbeissued.
Applicationswillbeassessedagainstthefoureligibilitycriteriaoutlinedonpage1.