RegisterBook

New Client Registrations

CLIENT REGISTRATION/ASSESSMENT FORM

If you are a frail older  person aged 65 years and over, or 50 years and over for Aboriginal and Torres Strait Islanders, please complete the form below AND also register through “My Aged Care” by telephoning 1800 200 422.  Please request “Community Transport – Ryde, Hunters Hill (Stryder)” as your preferred Service Provider.   “My Aged Care” has been established by the Australian Government to help you navigate the aged care system.  It has been designed to give people more choice, more control and easier access to a full range of aged care services.
If you are a person aged under 65, please contact the National Disability Insurance Scheme (NDIS) on 1800 800 110 to discuss your eligibility for an NDIS package, then please complete and submit the form below.  Thank you.

    PART A

    • Mr/Mrs/Miss/Ms/Dr:*

      Given Name:*

      Family Name:*

    • Date of Birth:*

      Age:*

      Male/Female*

    • Usual Address:*

      Postcode:*

    • Telephone:

      Mobile:

      Email:*

    • Current Address (if different):

      Postcode:

    PART B

    • Emergency Contact:*

      Telephone:*

      Relationship:*

    • Doctor's (GP) Name:*

      Doctor's Telephone:*

      Medicare No:*

    • Are you Aboriginal or Torres Strait Islander?

      Country of Birth:*

      Main Language:*

    • Do you have cultural or linguistic needs?

      Do you live alone?YesNo

      Do you have a carer?( if YES please complete Part F)YesNo

    PART C

    • Income:

      Pension - Aged

      Pension - DVA

      Pension - Disability

      Other

    • Living Arrangements:OwnedPrivate RentalPublic RentalOther

    PART D – What is your ability to

    • Do Housework?*Without HelpWith HelpCompletely Unable

    • Get places further than walking distance? (TRANSPORT)*Without HelpWith HelpNeed specialised vehicle or ambulance

    • Go out for SHOPPING for groceries and clothes?*Without HelpWith HelpCompletely Unable

    • Take your own MEDICATION?*Without HelpWith HelpCompletely Unable

    • Handle own MONEY?*Without HelpWith HelpCompletely Unable

    • To WALK? ie. walking stick, frame, wheelchair*Without HelpWith HelpCompletely Unable

    • To BATHE/SHOWER?*Without HelpWith HelpCompletely Unable

    • DRESS yourself?*Without HelpWith HelpCompletely Unable

    • EAT?*Without HelpWith HelpCompletely Unable

    • To the TOILET by yourself?*Without HelpWith HelpCompletely Unable

    • To get out of BED and MOVE around?*Without HelpWith HelpCompletely Unable

    • Do you need help to communicate?*NoSometimesAlways

    PART E

    • Do you have any health issues that will affect service delivery?

      Yes

      No

    • MOBILITY:

      Do you use:- Walking Stick

      Yes

      No

      Do you use:- Walking Frame

      Yes

      No

      Do you use:- Wheelchair

      Yes

      No

      Can you get in/out of our bus?YesNoUnsure

    • ACCESS TO HOME
      Is it safe for our vehicle to stop outside your home?

      CarYesNo

      BusYesNo

      Please state ALL access difficulties:

    • Do you need front seat of car?YesNo

      Do you need back seat of car?YesNo

    • Can you travel in a taxi?YesNo

      Do you haveGuide DogOxygen CylinderOther

    • Do you receive other services from Home & Community Care?YesNo

    • How did you find out about Community Transport?

    • BODY WEIGHT
      Are you:

      Do you require Bariatric Seat?

      Yes

      No

      Do you require Extension Seat Belt?

      Yes

      No

      Do you use other bariatric aids ?

      Yes

      No

    • I require transport for:

      MedicalSocialShopping

      Access to

    PART F (if applicable)

    Do you have a carer

    Yes

    No

    PART G

    I understand that by using this service I consent to Stryder Inc. supplying non-identifying information to their funding bodies for planning and statistical purposes. I understand that Stryder Inc. will seek my consent before referring me to another service. I understand that I will be notified in writing of the success or otherwise of my assessment and that I will receive a copy of the Passenger Handbook outlining my rights and responsibilities. I understand that from time to time photos or videos may be taken during the course of our activities and used for promotional purposes. I understand I can call the manager if I have concerns about any of the above information.
    I acknowledged the above.
    Please note, all applicants over the age of 65 wishing to have access to our subsidised rates must also contact “My Aged Care” and be referred to this service. Their number is 1800 200 422.

    • Date:

    captcha