Apply for accommodation

Step 1 of 6

Please select the accommodation you are applying for

Please SelectFull care room within main Ferguson Lodge buildingVilla, two-bedroom, self-care, fully accessible

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?*

Please SelectYesNo

If yes -

Are you of Aboriginal or Torres Strait Islander descent?

Please SelectAboriginalTorres Strait IslanderNeitherBoth

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*

Please SelectPermanentMedium term (Transitional)Short Stay

Accommodation start date*

Accommodation end date*

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

Please Select*Own HomeRentalNSW HousingSDA RegistrationOther

Please attach / Provide confirmation

Please provide details*.

Step 4 of 6

Date of Injury*

Are you a permanent resident of Australia*

Please Select*YesNo

Are you on a Pension?*

Please Select*YesNo

If yes state the type of Pension*

Please Select*Disability Support PensionAge Care PensionNewstartOther

If Other, please state*

Are you in employment?*

Please Select*YesNo

Are you a member of ParaQuad?*

Please Select*YesNo

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

Does your NDIS funding provide support for social integration?*

Please Select*YesNo

If yes - please describe*

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?*

Please Select*YesNo

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

Do you experience Autonomic Dysreflexia?*

Please Select*YesNo

If yes treatment used*

Do you have any Pressure Areas?*

Please Select*YesNo

Do you have any of the following Respiratory Conditions?

Overnight Sleep Apnoea*

Please Select*YesNo

If yes, do you use*

Please Select*CPAPBIPAP

Tracheostomy / Ventilated*

Please Select*YesNo

Recurrent Chest Infections?*

Please Select*YesNo

Asthma?*

Please Select*YesNo

Other?*

Please Select*YesNo

If yes?*

Have you had an assessment by a speech pathologist?*

Please Select*YesNo

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?*

Please Select*YesNo

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

Do you have diabetes?*

Please Select*YesNo

If yes please tick how your diabetes is managed below*

Diet ControlledMedicationInsulin

Do you smoke tobacco?*

Please Select*YesNo

If yes - How many cigarettes per day?*

Do you drink alcohol?*

Please Select*YesNo

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?*

Please Select*YesNo

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