COVID-19 response

As of Monday 18 May, the Civic Centre in Port Adelaide is open to the public.  Information about the opening of Council facilities is available here
For more detailed information about particular services that may have been impacted due to restrictions click here

Please contact us by phone 8405 6600, complete a request via our website or email service@cityofpae.sa.gov.au

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HACC - Assessment and Referral

Client Details
Enter your mobile number without spaces
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Date of birth * If over 65 please contact My Aged Care. http://www.myagedcare.com.au 1800200422
English Skills
Client Information
Lives with:
Group:
Accommodation
Income Source
Referral Form
Has resident given consent for this referral to Council?
Referral from
(Mr/Mrs/Ms)
Carer Information
Does the client have a carer who receives a Carer Allowance or Pension? If Yes complete this section, otherwise continue to next section.
Carer is emergency contact?
(Mr/Mrs/Ms)
Emergency Contacts
English Skills
Current Service Information
Comm Aged Care Package
HACC Package
Metro Dom Care
Meals on Wheels
RDNS
Other
Services Required
Council Services Required
Relevant Medical History
Proposed Discharge Date *
Client is at Home
History
Mobility Aides
OHWS Issues
Is Client Prone to Falls?
Does Client Have Pets?
Does Client Have Behavioural Issues? (ie: Cognitive, Personality, Dementia)
Attachments