Apply for accommodation

"*" indicates required fields

Please select the accommodation you are applying for*

Personal details

Full Name*

Home address*

State*

Postcode*

Mobile

Phone (other)

Date of birth*

Next of kin details

Name*

Relationship*

Email*

Phone

Mobile

Present address, if different to above

Present address

State

Postcode

Cultural background

What is your first language?*

Do you require an interpreter?*

If yes, which language?*

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?

Period of accommodation sought*

Cause of injury*

Date of injury*

Lesion level*

Lesion level status*

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

Care and support provider

Insurance (e.g. iCare)

Self funded

Other

NDIS details

Does your NDIS funding cover care / support hours?*

Does your NDIS funding provide support for social integration?*

Care and support provider details

Name of organisation*

Name of provider*

Number of hours funded per week*

Insurance details

Name of organisation*

Name of provider*

Number of hours funded per week*

Self funded details

Please give details*

Other funding details

Please give details*

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

Drop files here or

Accepted file types: jpg, png, jpeg, pdf, doc, docx, rtf, Max. file size: 128 MB.

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*

Pressure Grade (if known)

Current treatment*

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, please describe*

Have you had an assessment by a speech pathologist?*

If yes, please provide a copy of assessment

Documents must be no more than 3 months old

Drop files here or

Accepted file types: jpg, png, jpeg, pdf, doc, docx, rtf, Max. file size: 128 MB.

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

Drop files here or

Accepted file types: jpg, png, jpeg, pdf, doc, docx, rtf, Max. file size: 128 MB.

Do you have diabetes?*

If yes please tick how your diabetes is managed below

Diet Controlled

Medication

Insulin

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?*

Medications*

Please list all medications (prescribed and over the counter medication) currently used, how often 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

Drop files here or

Accepted file types: jpg, png, jpeg, pdf, doc, docx, rtf, Max. file size: 128 MB.

General practitioner contact details

Full name*

Address*

Phone*

Spinal specialist

Full name*

Hospital*

Phone*

Date last reviewed*

Who referred you / told you about Ferguson Lodge?

Name*

Relationship*

Phone

Got a question?

Talk to us for more information about our services and how we can help you.

Apply for accommodation

Personal details

Next of kin details

Present address, if different to above

Cultural background

NDIS details

Care and support provider details

Insurance details

Self funded details

Other funding details

Do you have any of the following Respiratory Conditions?

General practitioner contact details

Spinal specialist

Who referred you / told you about Ferguson Lodge?

Got a question?

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