Apply for accommodation

Fields marked with * are required.

Step 1 of 6

Please select the accommodation you are applying for


Step 2 of 6

Personal Details

Date of birth*

Next of Kin Details

Present Address, if different to above

Cultural Background

Do you require an interpreter?*

If yes -

Are you of Aboriginal or Torres Strait Islander descent?

Is there any thing we should be aware of so that we can ensure that we deliver culturally appropriate services to you:

Step 3 of 6

Period of accommodation sought*

Accommodation start date*

Accommodation end date*

Discharge Destination (must be fully wheelchair accessible OR meet your mobility needs)*

Please attach / Provide confirmation

Please provide details*.

Step 4 of 6

Date of Injury*

Are you a permanent resident of Australia*

Are you on a Pension?*

If yes state the type of Pension*

If Other, please state*

Are you in employment?*

Are you a member of ParaQuad?*

Current source of funding (Please tick and fill in the details)*

NDIS Participant

Does your NDIS funding cover care / support hours? *

Does your NDIS funding provide support for social integration?*

If yes - please describe*

Care and Support Provider
Insurance (e.g. iCare)
Self Funded

Please give details

Other

Please give details


Step 5 of 6

Medical History(We need your medical history to assess whether we can meet your needs)*

Please attach any referrals, discharge summaries, Doctors letters or other relevant information.Documents must be no more than 3 months old

Do you have any known Infections?*

If yes please provide details of the infection and current treatment/s*

Do you experience Autonomic Dysreflexia?*

If yes treatment used*

Do you have any Pressure Areas?*

If yes, please describe*

Do you have any of the following Respiratory Conditions?

Obstructive Sleep Apnoea (OSA)*

If yes, do you use*

Tracheostomy*

Ventilated*

Recurrent Chest Infections?*

Asthma?*

Other?*

If yes?*

Have you had an assessment by a speech pathologist?*

If yes please provide a copy of assessment (No more than 3 months old)?*

Do you have modified diet and/or mealtime assistance requirements when eating or drinking?*

If yes please provide a copy of all relevant documents for your modified diet and mealtime requirements.*

Do you have diabetes?*

If yes please tick how your diabetes is managed below*

Diet ControlledMedicationInsulin

Do you smoke tobacco?*

If yes - How many cigarettes per day?*

Do you drink alcohol?*

If yes - How many drinks per day?*

If yes - How many drinks per week?*


Step 6 of 6

Medications*

Please list all medications (prescribed and over the counter medication) currently used, how ofter do you take this medication and how long have you used this medication.

Other substance used*

Please list all other substance used (Illicit and other non-prescribed substances), frequency of use and how long have you used this substance.

Do you have any other medical conditions which may impact your care needs?*

If yes - Please provide details*

If yes - Please provide medical reports if applicable

General Practitioner Contact Details

Spinal Specialist

Date Last Reviewed*

Who referred you / told you about Ferguson Lodge?

If other, plese describe