Aged Care Volunteer Visitors Scheme Recipient Referral Form

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Preferred Visit Location

To help us match you with a suitable volunteer, please indicate the area where visits will take place. This is usually the location of the residential aged care facility or the recipient’s home. Matching within local areas helps ensure visits can occur regularly and consistently, providing the best possible support and companionship.

Which area will the recipient be receiving visits in?(Required)

Metro North: Subiaco, Joondalup, Mindarie and surrounds

Metro East: Inglewood, Beechboro, Midland and surrounds

Metro South East: Victoria Park, Cannington, Armadale and surrounds

Metro South West: Fremantle, Rockingham, Mandurah and surrounds

We are not currently accepting recipient referrals at this time due to limited availability.

Important:

We are not currently accepting recipient referrals in the area you selected due to limited availability.

We recommend exploring alternative providers through the Aged Care Volunteer Visitors Scheme (ACVVS) .

The ACVVS State Network Coordinator can assist in directing referrals to organisations that may still have capacity in your requested area.

Recipient Information

First Name of Recipient(Required)

Last Name of Recipient(Required)

Recipient's Date of Birth(Required)

Does the recipient live in an aged care facility?(Required)

Yes

Is the recipient receiving/approved for a home care package?(Required)

Yes

Aged Care Facility Name(Required)

Aged Care Facility Phone Number(Required)

Home Care Package Provider Name(Required)

Home Care Package Provider Phone(Required)

To be eligible to be a recipient in the ACVVS, one of the following must apply. They live:

in a residential aged care home
at home and are receiving/approved for a Home Care Package.

If neither of the above apply to your situation, please don't complete this form but call Lifeline WA's ACVVS Coordinator on 0425 661 816, 9261 4423 or Lifeline WA reception on 9261 4444.

Is it the recipient who is filling out this form?(Required)

Yes, I'm requesting a visitor for myself

No, I'm referring someone else to receive a visitor

Referrer's Full Name(Required)

Referrer's Relationship to Recipient(Required)

Referrer's Phone Number(Required)

Referrer's Email Address(Required)

Is it OK for the ACVVS Coordinator to contact the recipient directly?(Required)

Yes, the ACVVS Coordinator can contact the recipient directly

No, please contact me first

No, please contact the person below first

Contact Full Name(Required)

Contact Phone Number

Consent(Required)

I discussed this referral to Lifeline WA ACVVS with the named recipient and they have consented to this form being submitted.(Required)

Consent(Required)

I explained to the recipient that they will be matched with a visitor based on the preferences below, they can request a change of visitor or give feedback, and they can pause/withdraw participating at any time.(Required)

Recipient information

Recipient's home address where visit will take place(Required)

Recipient's Phone Number (if applicable)

Recipient's Emergency Contact Full Name(Required)

Recipient's Emergency Contact Relationship(Required)

Recipient's Emergency Contact Number(Required)

Country of Birth(Required)

Preferred Language(Required)

Gender Identity & Preferred Pronouns

Does the recipient identify as being part of any of the following groups, as specified under the Aged Care Act 1997?(Required)

From Aboriginal and Torres Strait Islander communities

From culturally and linguistically diverse background

Financially or socially disadvantaged

Veterans

Lesbian, gay, bisexual, transgender and intersex

Care leavers - people separated from their children by forced adoption or removal

People who are homeless, or at risk of becoming homeless

No, none of the above apply

Tick all that apply.

Reason for requesting a visitor(Required)

Current visitors(Required)

Background – family/culture/work history(Required)

Hobbies & interests(Required)

Recipient's health

Please indicate, and give brief notes on, each of the below that apply to the recipient.

Cognitive impairment/dementia(Required)

Yes

Details of cognitive impairment/dementia(Required)

Deaf/hearing impairment(Required)

Yes

Details of hearing impairment(Required)

Speech challenges(Required)

Yes

Details of speech challenges(Required)

Vision impairment(Required)

Yes

Details of vision impairment(Required)

Diagnosed mental illness/mental health concern/significant trauma(Required)

Yes

Details of any mental health illness/concern(Required)

Mobility challenges(Required)

Yes

Details of mobility challenges(Required)

Continence challenges(Required)

Yes

Details of continence challenges(Required)

Other disability(Required)

Yes

Details of other disability(Required)

Any other behaviour/s

Can the recipient go on outings without personal care support?(Required)

Yes

What support does the recipient need for an outing?(Required)

Any other relevant health information?

Do you have preferences about the visitor?

Their gender(Required)

Their age(Required)

Any

18-35 years of age

36-45 years of age

46 years of age and over

Do you have any other preferences for the visitor?

Optional

What activities will the recipient and visitor likely do together?(Required)

Any other comments?

How did you hear about us?(Required)

ACVVS Recipient Availability

Recipient referral form

Preferred Visit Location

We are not currently accepting recipient referrals at this time due to limited availability.

Recipient Information

Recipient information

Recipient's health

Do you have preferences about the visitor?

How you can help

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