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Apply Online for Aged Care

Carinity Application Form

Step 1 of 6

16%

Carinity community preference

In order of preference, please number the Carinity communities you are interested in. If you are only interested in one community there is no need to nominate any other preferences.*

Unsure on what communities are on offer? Click here to view all Carinity communities.

Preference 1
Select community*
Community Preference
Have you completed a tour of your preferred community?
- Yes
- No
Care requirements*
- Permanent
- Respite (high care)
- Memory-Assisted Living (Dementia secure environment)
How soon is care required?
- Immediately
- Within the next 3 months
- Within the next 12 months
- Other
If respite selected, date required from:
DD slash MM slash YYYY

Please note: respite accommodation is not available at all communities. Our Customer Service Team will advise you if your chosen community does not offer respite.

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Person requiring care (Applicant Details)
First name*
Last name*
Preferred name
Date of Birth*
DD slash MM slash YYYY
Gender*
Contact Information
Current location*
Street address
Suburb
State
Postcode
Phone
Mobile phone
Email address
Additional Information
Are you a smoker?
- Yes
- No
Carinity Communities are non-smoking
Marital Status
Religion (optional)
Country of birth
Main language spoken
Interpreter needed
- Yes
- No
Medicare Details
Medicare number
Reference number
Expiry: Month
Expiry: Year
Do you hold an Australian Pension Concession card?
- Yes
- No
Please indicate the type of pension
Please select one of the following:
Pension Concession Card Number
Have you been in Permanent Residential Aged Care Accommodation before?
- Yes
- No
Date of Admission
DD slash MM slash YYYY
Name of Facility
If you have a copy of a recent Income and Assets Summary from Services Australia, please attach here.
Income and Assets Summary
Max. file size: 256 MB.
Upload your Income and Assets Summary

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Health Information
Have you had an ACAT assessment*
- Yes
- No
- Unsure
If you’re thinking about moving into an aged care community that is subsidised by the Australian Government, you will first need an assessment with a member of an Aged Care Assessment Team (ACAT). To find your local ACAT, organise a free assessment, or for more information about ACAT assessments, visit myagedcare.gov.au or call 1800 200 422.
My Aged Care - Residential Permanent Referral Code*
My Aged Care - Respite Referral Code
If your ACAT was completed more than three months ago, please request a Medical Health Summary from your General Practitioner and send to agedcare@carinity.org.au. Alternatively, if you have it available now you can upload it below.
Medical Health Summary
Max. file size: 256 MB.
Upload your Medical Health Summary
How would you describe your level of mobility?*
- Independently mobile
- Assistance required
- Not mobile
What mobility assistance do you require (including the number of people required to assist you)
Do you require a mobility aid?
- Yes
- No
Please describe
Do you require a specific diet (for example soft diet)
- Yes
- No
Please describe
Do you require hygiene assistance?
- Yes
- No
Please describe
Do you have urinary or faecal incontinence?
- Yes
- No
Please describe
Do you have vision impairment?
- Yes
- No
Please describe
Do you have hearing impairment?
- Yes
- No
Please describe
Do you require pain management?
- Yes
- No
Please describe
Do you require assistance with meals?
- Yes
- No
Please describe
Do you require a toilet aid (eg. raised toilet seat/ commode)
- Yes
- No
Please describe
Do you require toileting assistance?
- Yes
- No
Please describe
Have you had a recent weight loss?
- Yes
- No
Please describe
What is your current weight?
Do you have a history of falls?
- Yes
- No
Please describe
Do you require assistance when taking medication?
- Yes
- No
Do you require oxygen?
- Yes
- No
Do you require enteral feeding?
- Yes
- No
Do you have a tracheotomy?
- Yes
- No
Do you require a catheter?
- Yes
- No
Do you have a stoma?
- Yes
- No
Do you require peritoneal dialysis?
- Yes
- No
Do you require daily injections?
- Yes
- No
Please describe
Do you require complex wound management?
- Yes
- No
Please describe
Do you have any known allergies?
- Yes
- No
Please describe
Do you have wandering tendencies?
- Yes
- No
Please describe
Do you have any form of dementia?
- Yes
- No
Please describe
Do you have a mental health diagnosis?
- Yes
- No
Please describe type of disorder and treatment
Please provide name of physician and contact details
Upload any other relevant health information (including Hospital discharge summary or care plan)
Drop files here or

Max. file size: 256 MB.

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Details of person submitting this application form
What is your relationship to the person requiring care? (select all that apply)*
- Myself
- Spouse
- Child
- Friend
- Relative
- Health care professional
- Placement consultant
- EPOA
- Other
Please provide details of someone who we should contact for important information about your care
Please provide your contact details
First name*
Last name*
Street address
Suburb
State
Postcode
Phone*
Email address
Drivers Licence Number
Have you been nominated as a legal representative?
- Yes
- No
Please select your role(s)
- Administrator
- Enduring Power of Attorney (personal and health)
- Enduring Power of Attorney (financial)
- Guardian
- Power of Attorney (financial only)

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Legal and Financial Management Details
Have any of the following representatives been appointed on your behalf? (select all that apply)
- Administrator
- Enduring Power of Attorney (personal and health)
- Enduring Power of Attorney (financial)
- Guardian
- Power of Attorney (financial only)
- None of the above
Have any other representatives been appointed on the applicant's behalf? (select all that apply)
- Administrator
- Enduring Power of Attorney (personal and health)
- Enduring Power of Attorney (financial)
- Guardian
- Power of Attorney (financial only)
- None of the above
Have any representatives been appointed on the applicant's behalf? (select all that apply)
- Administrator
- Enduring Power of Attorney
- Guardian
- Power of Attorney (financial only)
- None of the above
Please provide the names and addresses of person/s appointed.
If they were listed in the previous step, please complete the Name/Organisation field only.
Name/Organisation*
Street address
Suburb
State
Postcode
Phone
Email address
What is their relationship to you?*
- Spouse
- Child
- Friend
- Relative
- Other
What is their relationship to the applicant?*
- Spouse
- Child
- Friend
- Relative
- Other
If you have more than one representative please list their name, address and contact details here

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Please share any other information that is relevant to this Application
How did you hear about us?
- Advertising
- Carinity website
- Existing client
- Word of mouth
- Hospital/ Health care professional
- Placement consultant
- Other
To view our privacy policy https://carinity.org.au/privacy-policy/
CAPTCHA
Name
This field is for validation purposes and should be left unchanged.

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Carinity acknowledges the Traditional Custodians of country throughout Queensland and their connections to land, sea and community. We pay respect to their Elders past and present and extend that respect to all Aboriginal and Torres Strait Islander peoples today.

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Carinity Application Form

Step 1 of 6

Carinity community preference