Date of Birth:
Surname:
First Name:
SLK
WA HACC ELIGIBILITY AND CLIENT ASSESSMENT FORM
Items marked with an * asterisk are mandatory fields required for entering data in the WAAFI.
*Referrer/Caller First Given Name:
CALLER/REFERRER DETAILS
*Referrer/Caller Surname/Family Name:
Referrer/Caller Contact Details:
Caller/Referrer Type:
Organisation: ____________________________
Position: ________________________________
*Phone Number: _______________________
Fax Number: ____________________________
Email Address: __________________________
(Not stated/inadequately described; Aboriginal Health Service; ACAT;
*Title:
(Mr/Mrs/Ms/Miss/Dr/Fr/Br/Sr/Not stated)
Preferred Name:
CLIENT DETAILS
*First Given Name:
*Date of Birth:
*Gender:
Male
Community Nursing or Health Services; Extended Care/Rehabilitation
Facility; Family, significant other, friend; GP/Medical Practitioner communitybased; Hospital; Health Professional; DSC; Self; Other; Other Community
Based Service; Other Medical/health Facility; Psychiatric/mental health
service or facility; Residential aged care facility; Law enforcement agency).
Female
*Surname/Family Name:
*Date of Birth estimated:
Medicare Number:
Yes
No
IRN:
Contact Details:
*Address:
________________________________________ *Home Telephone Number: _____________________
Work/Other Telephone Number _________________
Mobile Telephone Number _____________________
Postal Address (if different from above):
Email Address: ______________________________
________________________________________
________________________________________
*Main language spoken at home:
Is an interpreter required?:
Yes
No
Details:
(Includes sign language; Makaton; Auslan)
*Country of Birth:
*Living Arrangement:
*DVA Card Status:
Lives alone
Lives with others
DVA Gold Card
Other DVA Card
Lives with family
Not stated
DVA White Card
*Accommodation Setting:
(Private residence – owned/purchasing; Private residence – private rental; Private residence – public rental; Independent living unit within a
retirement village; Boarding house/private hotel; Short term crisis, emergency or transitional accommodation facility (includes Temporary shelter
within an Aboriginal community); Supported accommodation or supported living facility (includes Domestic-scale supported living facility and
Supported accommodation facility); Institutional setting; Public place/temporary shelter; Private residence rented from an Aboriginal Community;
Other; Not stated/inadequately described)
*Indigenous Status:
Aboriginal but not Torres Strait Islander
Origin
Torres Strait Islander but not Aboriginal
Origin
Both Aboriginal and Torres Strait Islander
Origin
Neither Aboriginal nor Torres Strait Islander
Origin
Not stated/inadequately described
Version 3
*Pensioner Benefit Status:
Age Pension Related Benefit
Veterans’ Affairs (Pensions)
Disability Support Pension
Unemployment
Carer Payment (Pension)
Other Government Pension Benefit
No Government Pension or Benefit
Review Date: 20 January 2015
Page 1
Date of Birth:
Surname:
First Name:
SLK
At time of screening for eligibility: If the client is not able to express their needs or client/carer is
distressed refer direct to RAS at this point of interview.
WA HACC Eligibility Form not completed
*Provide reason why:
For Regional Assessment Service
Reason assessment did not proceed:
(Client/Carer declined; Redirection to more appropriate specialist services; Not HACC Eligible; Improved Circumstances; Other – provide
comment)
Comments:
CLIENT ELIGIBILITY QUESTIONS
*Do you, or the person you care for, live in the community?
Yes
No
This excludes Commonwealth funded residential care, Disability Services Commission and
other funded group homes and mental health funded hostels
*Do you, or the person you care for, have an ongoing functional disability which impacts on your/their
ability to carry out day to day personal, household and social activities?
Yes
No
Answering ‘yes’ to this question will make the functional screening questions
(on page 3) mandatory in WAAFI.
*Do you, or the person you care for, have a mental health condition (eg depression/anxiety) which
impacts on your/their ability to carry out day to day personal, household and social activities?
Yes
No
*If YES, are you receiving any support from a service provider/clinic?
Yes
No
Unknown
*If YES, provide details if known.
*What difficulties are you currently experiencing that have led to your call?
How have you been managing until now?
If you don’t receive support will you be at risk of not being able to live in the community?
How long do you think you will need support?
Have you been discharged from hospital in the last three months?
Yes
No
If YES provide details:
*Are you or anyone in your house receiving any assistance from a service provider (e.g. household help,
gardening, meals, transport or shopping)?
Yes
No
*Provide details
*Are you, or the person you care for, getting any other type of assistance (e.g. family, friends and/or
carer)?
Yes
No
*If YES, provide details
Are you interested in a short term (6-12 week) service that will support you to retain/regain your
independence?
Yes
No
Version 3
Review Date: 20 January 2015
Page 2
Date of Birth:
Surname:
First Name:
SLK
All Functional Screen fields below are mandatory.
*Functional SCREEN Domestic and Self Care Functional Needs Identification
Independent
Needs some
Dependent
DOMESTIC & SELF CARE
assistance
(manages
without
(completely
unable
FUNCTIONS
*Can you do your housework?
*Can you get to places out of walking
distance?
*Can you walk (up to 20 metres)
*Can you climb or descend stairs?
*Can you go out shopping for groceries
or clothes (assuming you have access
to transport)?
*Can you handle your own money?
*Can you take your own medicine?
*Can you prepare your own food?
*Can you manage your eating?
*Can you do your laundry (not including
ironing)?
*Do you ever need help to get out of
bed, or move around at home (or places
away from home)?
*Can you take a bath or shower?
*Can you dress yourself?
*Can you manage your grooming?
*Can you manage your bowels (faecal
continence) and your bladder?
*Can you manage your toilet use?
*Do you ever need help to
communicate?
*Can you use the telephone?
Totals
CARER SUPPORT
help)
3
(with some help)
2
to manage)
1
Independence
Needs Assistance
Dependency
Yes/Always
3
Sometimes
2
No/Never
1
NO = 0
Yes = 2
*Do you currently get regular help from
a family member or an unpaid carer for
domestic and/or self-care tasks?
*If you currently get help from a family
member or an unpaid carer is this help
likely to be ongoing?
COGNITION AND BEHAVIOUR
(do not ask the client)
*Does the person have any memory problems or get
confused?
*Does the person have any behavioural problems?
Version 3
Review Date: 20 January 2015
Page 3
Date of Birth:
Surname:
First Name:
Carer’s SLK:
SLK
CARER SUPPLEMENT (CARER MDS SCREEN)
No/Yes (If YES consider need for face to face assessment and/or referral to NRCP)
*Is there a carer?:
Yes
No
*Does the carer live with the client?
Co-resident
*Relationship to client:
(Spouse/partner; Parent; Son or daughter; Son-in-law or daughter-inlaw; Other relative; Friend/neighbour; Not stated/inadequately
described):
Non-resident
Title: (Mr/Mrs/Ms/Miss/Dr/Fr/Br/Sr)
*Carer’s First Given Name:
*Carer’s Surname/Family Name:
Carer’s Preferred Name:
*Carer’s Date of Birth:
*Carer’s Gender:
Male
Female
Not stated
*Carer’s Date of Birth estimated:
Yes
No
*Carer’s Address: __________________________ Carer’s Contact Details:
__________________________________ Home Telephone Number: __________________
__________________________________ Work/Other Telephone Number ______________
__________________________________
__________________________________
Does the carer work?
Yes
No
Mobile Telephone Number __________________
Email Address: ____________________________
*If yes,
Full Time
*Main language spoken at home by carer:
Is an interpreter required:
*Country of Birth:
Interpreter details:
*Indigenous Status:
Aboriginal but not Torres Strait Islander Origin
Torres Strait Islander but not Aboriginal Origin
Both Aboriginal and Torres Strait Islander Origin
Does the carer need support?
Yes
No
Part Time
Yes
No
Neither Aboriginal nor Torres Strait
Islander origin
Not stated/inadequately described
*Carer provides assistance to more than one
person
Yes
No
IF CALLER IS THE CARER THE FOLLOWING QUESTIONS ARE TO BE COMPLETED
CARER NEEDS (ELIGIBILITY)
If a care recipient is eligible to receive services funded under the HACC Program, then that person’s
carer is eligible for HACC funded respite and counselling, support, information and advocacy services.
However, if the identified carer is eligible for other HACC funded service types in his or her own right, a
separate CNI should be completed for that person:
Has another service provider completed a Carer Supplement for you?
Yes
No
If YES seek further details, eg name of agency and contact details.
What difficulties are you currently experiencing that have led to your call?
How have you been managing until now?
Version 3
Review Date: 20 January 2015
Page 4
Date of Birth:
Surname:
First Name:
SLK
EMERGENCY CONTACT DETAILS (IF DIFFERENT FROM CARER)
*Do you have someone you would like us to contact in an emergency?
Yes
If YES, provide details:
No
Title:
*Surname/Family Name:
*First Given Name:
Relationship to client:
Preferred Name:
(Spouse/partner; Parent; Son or daughter; Son-in-law or daughter-inlaw; Other relative; Friend/neighbour; Not stated/inadequately described)
Address: _______________________________
________________________________
Contact Details:
*Home Telephone Number: __________________
Work/Other Telephone Number ________________
________________________________
Mobile Telephone Number ____________________
Email Address: _____________________________
SECONDARY EMERGENCY CONTACT DETAILS (IF AVAILABLE)
Title:
*Surname/Family Name:
*First Given Name:
Relationship to client:
(Drop down menu to select Family Member (Drop down
Preferred Name:
menu to select Spouse/partner; Parent; Son or daughter; Son-in-law or
daughter-in-law; Other relative; Friend/neighbour; Not
stated/inadequately described):
Address: _______________________________
Contact Details:
________________________________
________________________________
*Home Telephone Number: __________________
Work/Other Telephone Number ________________
________________________________
Mobile Telephone Number ____________________
________________________________
Email Address: _____________________________
INFORMATION SHARING
Read the following statement to the potential client/carer:
It may be necessary to provide information about you to other individuals and agencies to ensure the
most appropriate community care and support services can be provided to you and/or the person for
whom you provide care. In addition, de-identified demographic and service provision information is
routinely provided to the HACC Program for planning purposes. You can withdraw your consent to the
sharing of your personal information at any time.
*Statement has been explained to the Client
Yes
No
*Statement has been explained to the Carer
Yes
No
*Variation made by client/carer
*If YES provide details
Yes
No
Version 3
Review Date: 20 January 2015
Page 5
Date of Birth:
Surname:
First Name:
SLK
SCREENING PERSONNEL DETAILS
Screening Personnel Name(s):
Eligibility Screen Date:
Organisation:
ELIGIBILITY SCREEN OUTCOME
Appears eligible and referred to:
Appears ineligible and reason:
Ineligible and referred for appeal to:
WA HACC ELIGIBILITY AND CLIENT ASSESSMENT FORM
*Face to face assessment
Yes
No
*If NO reason why: _______________________________________________________________
Date Completed:
Recommended Review Date:
Assessment
Reassessment
Review
No Review required
(Drop down menu to select: Client no longer needs assistance – improved
status; Client only required one off service e.g. equipment, Home
modifications; Client moved to residential care; Client moved to other
community based service, e.g. Commonwealth Funded programs; Client
terminated services; Client died; Other
CORE ASSESSMENT INFORMATION
CLIENT CURRENT STATUS
Is the client currently receiving any formal assistance from a Government funded program ( HACC or Non –
HACC)
Yes
No
*Provide details (mandatory when yes)
Self-reported health conditions
Impact of condition (ie fatigue, pain, reduced mobility, fear, balance issues, isolation, confusion, memory
loss, disturbed sleeping patterns)
Are you happy to provide your GPs details?
No
Yes
(provide details)
Name of GP:
Version 3
Name of Medical Centre/Practice:
Review Date: 20 January 2015
Page 6
Date of Birth:
Surname:
First Name:
SLK
Contact Details:
Address: _________________________________
Work/Other Telephone Number _______________
__________________________________
Mobile Telephone Number ___________________
Fax Number ____________________________
__________________________________
Email Address: _____________________________
How satisfied is the client with their current level of independence?
1
2
Not at all Satisfied
3
4
5
Very Satisfied
Comments:
Version 3
Review Date: 20 January 2015
Page 7
Date of Birth:
Surname:
First Name:
SLK
CLIENT CURRENT STATUS - CONTINUED
Is a referral to a short term enablement program required? eg Home Independence Program (HIP)
No
Yes
(provide details):
COMMUNICATION
1. If some assistance or dependency is noted DETAILS MUST BE PROVIDED of the client’s
abilities, difficulties and any support required.
2. Note any use of equipment which supports the client’s independence
3. If client is completely independent and does not use equipment/aids, ticking this box will close
this section
Independent in all areas
Vision
Dependent
Some assistance
Independent
Hearing
Dependent
Some assistance
Independent
(1)
(2)
(3)
(1)
(2)
(3)
Speech
Dependent
Some assistance
Independent
(1)
(2)
(3)
FUNCTIONAL ASSESSMENT
MOBILITY, BALANCE AND TRANSFERS
1. If some assistance or dependency is noted DETAILS MUST BE PROVIDED of the client’s
abilities, difficulties and any support required.
2. Note any use of equipment which supports the client’s independence
3. If client is completely independent and does not use equipment/aids, ticking this box will close
this section
Independent in all areas
Mobility within home
Dependent
(1)
Some assistance
(2)
Independent
(3)
Mobility outside of home
Dependent
(1)
Some assistance
(2)
Independent
(3)
Transfers ie bed, chair,
toilet and shower
Dependent
(1)
Some assistance
(2)
Independent
(3)
Using steps
Dependent
(1)
Some assistance
(2)
Independent
(3)
Version 3
Review Date: 20 January 2015
Page 8
Date of Birth:
Surname:
First Name:
SLK
MOBILITY, BALANCE AND TRANSFERS - CONTINUED
Environmental Assessment
Does the home environment have any barriers to the client’s independence?
No
Don’t Know
Yes
If YES record further information and consider referral to appropriate service provider for home modifications
as required. (See WA Assessment Framework – Suggested Referral Pathways for Equipment and Home
Modifications for HACC Eligible Clients)
Modes of transport to access community (Drop down box: taxi; bus; drives self, other)
*Falls, stumbles or near misses inside/outside the home in the last three to six months
No
Yes :
*Provide details:
If YES has the client attended a falls prevention program?
No
Yes
Provide details:
If NO would the client consider attending a falls prevention program?
Provide details:
SELF CARE
1. If some assistance or dependency is noted DETAILS MUST BE PROVIDED of the client’s
abilities, difficulties and any support required.
2. Note any use of equipment which supports the client’s independence
3. If client is completely independent and does not use equipment/aids, ticking this box will close
this section
Independent in all areas
Bathing and showering
Dependent
(1)
Some assistance
(2)
Independent
(3)
Dressing/undressing
Dependent
(1)
Some assistance
(2)
Independent
(3)
Grooming
Dependent
(1)
Some assistance
(2)
Independent
(3)
Toileting
Dependent
(1)
Some assistance
(2)
Independent
(3)
Version 3
Review Date: 20 January 2015
Page 9
Date of Birth:
Surname:
First Name:
SLK
Continence
1. If some assistance or dependency is noted DETAILS MUST BE PROVIDED of the client’s
abilities, difficulties and any support required.
2. Note any use of equipment which supports the client’s independence
3. If client is completely independent and does not use equipment/aids, ticking this box will close
this section
Independent in all areas
Faecal Continence
Dependent
(1)
Some assistance
(2)
Independent
(3)
Urinary Continence
Dependent
(1)
Some assistance
(2)
Independent
(3)
Continence Aids / Pads
Dependent
(1)
Some assistance
(2)
Independent
(3)
Does the client have any other bowel or bladder problems (eg constipation, pain/difficulty in passing stool,
increased need to urinate at night, abnormal bowel pattern, frequent diarrhoea or frequent urination?)
No
Yes
Provide details:____________________
Has the client discussed their continence issues with anyone, eg GP/Continence Nurse Advisor?
No
Yes
Provide details:____________________
Would the client like to discuss their continence issues with the Continence Management Advice Service?
(CMAS)
No
Yes
Provide details:____________________
Medication Management
Dependent
Some assistance
Independent
(1)
(2)
(3)
Describe medication
management (e.g. packet,
dossette, blister pack,
other)
Eating and Drinking
Dependent
(1)
Some assistance
(2)
Independent
(3)
Note any nutritional
requirements
Version 3
Review Date: 20 January 2015
Page 10
Date of Birth:
Surname:
First Name:
SLK
EVERYDAY ACTIVITIES
1. If some assistance or dependency is noted DETAILS MUST BE PROVIDED of the client’s
abilities, difficulties and any support required.
2. Note any use of equipment which supports the client’s independence
3. If client is completely independent and does not use equipment/aids, ticking this box will close
this section
Independent in all areas
Food Preparation
Cooking and/or
preparing food/drinks
Dependent
(1)
Some assistance
(2)
Independent
(3)
Note any special dietary
considerations/food
allergies
Shopping: eg
groceries/clothes
Dependent
Some assistance
Independent
(1)
(2)
(3)
Housekeeping Duties
Dependent
Some assistance
Independent
(1)
(2)
(3)
Household
Management
Includes legal affairs,
money management
and/or banking
Dependent
(1)
Some assistance
(2)
Independent
(3)
General Home
Maintenance
(including gardening)
Dependent
Some assistance
Independent
(1)
(2)
(3)
CARERS AND EQUIPMENT
Does the carer need to use equipment in their caring role? No
Yes
Provide details:____________________
Is the carer confident in using the equipment? No
Yes
Provide details:____________________
Version 3
Review Date: 20 January 2015
Page 11
Date of Birth:
Surname:
First Name:
SLK
SOCIAL NETWORKS AND COMMUNITY ACTIVITIES
Describe the client’s current support networks and involvement in social and community activities
(includes voluntary, employment, educational activities):
How satisfied is the client with their current involvement in social activities and interests?
1
2
Not at all Satisfied
3
4
5
Very Satisfied
If the client identifies a low level of satisfaction continue with questions (a) and (b):
a) Identify if the client ever feels lonely and/or sad
b) Describe what the client would like to be able to do and what is currently preventing them from being
involved?
PERSONAL STORY/SOCIAL HISTORY
Details of day to day routines, likes and dislikes, recent or significant life events, cultural and religious
observances, occupations, hobbies and interests, sleeping patterns
Details of any information regarding the clients social situation that may need to be considered as part of
recommendation for support
Describe any cognitive or mental health problems (including depression, anxiety, behaviours of concern)
identified that may need to be considered as part of the recommendations for support
Other relevant information
DESIRED OUTCOMES/REFERRALS WHERE IDENTIFIED
Has a referral for ACAT comprehensive assessment been made on behalf of the client?
No
Yes
Provide details:______________________________________________
Has a referral to a specialist provider been made on behalf of the client?: (ie CAEP, Occupational
Therapist, Physiotherapist, Podiatry, Continence Management and Advice Service)
No
Yes
Provide details:__________________________________________________
Version 3
Review Date: 20 January 2015
Page 12
Date of Birth:
Surname:
First Name:
SLK
DESIRED OUTCOMES/REFERRALS WHERE IDENTIFIED - CONTINUED
Has information been provided on how to access peak body support? (ie Association for the Blind,
Alzheimer’s Australia WA, Neurocare, Carer’s WA, Advocare)
No
Yes
Provide details:______________________________________________________
Has information been provided on how to access other agencies/community resources outside
the HACC Program to support the client’s goals and independence?
No
Yes
Provide details:____________________________________________________
Other referrals, outside of HACC support, made on behalf of the client:
No
Yes
Provide details:__________________________________________________________
*Appropriate information has been provided to ensure client is informed of their rights and responsibilities
and the complaints process.
No
Yes
*If NO provide reason why:
Do you have someone who advocates for you or who is authorised to act on your behalf?
No
Yes
(provide details)
Name:
Relationship to client:
(Drop down menu to select Advocate/Enduring Power of
Attorney/Enduring Power of Guardianship)
ASSESSOR DETAILS
Assessors Name(s):
Date:
Regional Assessment Service Site:
Contact Telephone Number:
Others Present at Assessment:
*Name/s:
Version 3
No
Yes
If yes, name and relationship mandatory
(enter details below).
*Relationship to client
Review Date: 20 January 2015
Page 13
Date of Birth:
Surname:
First Name:
SLK
CAPACITY TO CONTRIBUTE HACC FEES FOR SUPPORT
Client has been provided with a copy of the WA HACC Standard Fees Schedule.
Yes
No




Client has been advised:
They will be asked to pay a fee as a contribution towards the cost of the support that they
receive;
The service provider(s) will discuss the fees to be charged when the support plan has
been finalised;
If they are experiencing financial difficulty they may complete a Confidential Client Fee
Reduction Form and may have their fees reduced for a period; and
No person will be refused HACC support based on their inability to pay fees.
Client has indicated they have the capacity to pay fees:
Yes
No
Provide details:
Version 3
Review Date: 20 January 2015
Page 14
Date of Birth:
Surname:
First Name:
SLK
OSH SCREEN - OBSERVATIONS
This is a summary of the Assessor’s initial observations at the time of assessment and is not
intended to replace the service provider’s responsibilities under the Occupational Safety and
Health Act 1984. If a risk is observed, it is recommended that the SERVICE PROVIDER assess the
risk further when they conduct their regular RISK ASSESSMENT.
To be used in conjunction with the Guidance Notes for WA HACC Assessment
OSH Screen not completed
*Provide details of reasons why (mandatory if box ticked):_______________________________________
Access and Egress
Nothing observed
Risk identified
Provide details_________________________________________________________________________
Chemicals
Nothing observed
Risk identified
Provide details_________________________________________________________________________
Electrical
Nothing observed
Risk identified
Provide details:_______________________________________________________________________
Emergency, Fire, Burns
Nothing observed
Risk identified
Provide details: _______________________________________________________________________
Manual Tasks
Nothing observed
Risk identified
Provide details:________________________________________________________________________
Oxygen
Nothing observed
Risk identified
Provide details:________________________________________________________________________
Pets
Nothing observed
Risk identified
Provide details:________________________________________________________________________
Pests
Nothing observed
Risk identified
Provide details:________________________________________________________________________
Security
Nothing observed
Risk identified
Provide details: _______________________________________________________________________
Slips, trips and falls
Nothing observed
Risk identified
Provide details: _______________________________________________________________________
Smokers in the Home
Nothing observed
Risk identified
Provide details: _______________________________________________________________________
Traffic
Nothing observed
Risk identified
Provide details: ________________________________________________________________________
Violence and aggression
Nothing observed
Risk identified
Provide details: _______________________________________________________________________
Other
Nothing observed
Risk identified
Provide details: _______________________________________________________________________
Version 3
Review Date: 20 January 2015
Page 15