ACVVS Recipient Referral Form

Privacy Statement

Ageing with Grace collects the information in this referral form to assess eligibility and coordinate support through the Aged Care Volunteer Visitors Scheme (ACVVS). Information is stored securely in accordance with the Privacy Act 1988 (Cth) and the Australian Privacy Principles. Access is limited to authorised staff, and only information that is relevant will be shared with appropriate parties involved in coordinating or delivering the service. De-identified information may also be used for reporting, evaluation, and statistical purposes. Information will not be used or disclosed for any other purpose without consent, unless required or authorised by law.

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Email *
Date  *
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Who has given verbal/written consent* to submit this referral? 

Has this service been discussed with the older person? If they are unable to decide, has it been discussed with their representative? Are they happy to have a visitor?
Clear selection
Name of person providing consent
Relationship/Position
Organisation
Care Recipient Aged Care Status - must be one of the below to receive this service.  *
Type of visit requested *
Care Recipient First Name *
Care Recipient Surname *
Date of Birth *
Gender Identity *
Full address (either of the aged care home or for recipients on Support at Home package - their place of residence)
Country of Origin *
Preferred languages *
Reason for referral *
Background and Interests
Religion / Faith
Does the recipient have any pets? Provide details. 
Please indicate whether the older person identifies with any of the following groups or experiences (tick all that apply) *
Required
If you ticked "Person living with cognitive impairment, including dementia", please include level of dementia and any further details to assist us in matching. 
Current Visitors
Suggested Activities
Is the recipient interested in going on outings? 
Clear selection

To ensure ACVVS volunteer wellbeing and successful outings, please advise of any considerations not mentioned above (eg: ability to use toilet independently, ability to independently consume food/beverages, etc).

In the event of lockdown at a residential aged care home, virtual visits may be offered. Please indicate what types of virtual visit the care recipient would prefer (tick as many as apply)  

Visitor Preference - please indicate the recipient's preferences for the volunteer visitor. eg. gender, diversity, age
Please include any health or background information and/or preferences that will help match the recipient with a compatible volunteer. eg. physical ability limitations, hobbies, military service. 
HOME CARE PACKAGE RECIPIENTS ONLY. 
Please provide an Emergency Contact. Please include full name, relationship to recipient and contact phone number. 
About the Referrer 
Full Name
 *
Relationship to recipient
Organisation
Phone *
Email *
Name of Aged Care Provider 
Contact Person
Phone
Email
A copy of your responses will be emailed to the address you provided.
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