Residency | Cotlew Manor

Interested in accommodation at Cotlew Manor?

Fill out the form below! We pride ourselves on being able to take care of our residents needs on an individual basis. On completion of the application form, one of our administrators will contact you as soon as possible after reviewing your application!

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Applicant Details
Name*
First Last
Gender*
Date of Birth*

DD
MM
YYYY
Contact Phone No.*
Email
Current/Last Place of Residence*
Street Address Address Line 2 City State or Territory Post Code Country

Next of Kin Details
Relationship To Applicant*
Name*
First Last
Gender*
Primary Phone No.*
Secondary Phone No.
Email
Current Adress*
Street Address Address Line 2 City State or Territory Post Code Country

Pension Information
Pension Type*
Pension No.*
Expiry Date*
Medicare & Private Health Cover Information
Medicare Card No.*
Name's position number on card*
Month of Expiry*
Year of Expiry*
Do you have private health cover?*
Private Health Insurer Name
Customer No.
Current Doctor Details
Doctors Name
Practice Name and Suburb
Practice Phone No.
Substitute Decision Maker
POA and/or Guardian*
Do you have a substitute decision maker such as, Public Trustee, Protective Commision, Adult Guardian or a Power of Attorney?
POA and/or Guardian Details

Involuntary Treatment Order (ITO)
Are you under an ITO?*
What type of ITO are you under
Allergies and Health Information
Do you have any Allergies?*
Please provide details of your allergies
Do you have Self-Injurious Behaviour?*
Please provide details of your Self-Injurious Behaviour
Do you have a history of substance abuse?*
Please provide details of your substance abuse
Have you caused property damage maliciously or otherwise? i.e. Caused a fire*
Please provide details of property damage
Do you have Aggressive Behaviour?*
Please provide details of your aggressive behaviour
Do you suffer from Depression?*
Please provide details of your Depression
Do you suffer from a Sight Impairment?*
Please provide details of your Sight Impairment
Do you suffer from a Hearing Impairment?*
Please provide details of your hearing impairment
Do you suffer from a Speech Impediment?*
Please provide details of your speech impediment
Do you suffer from a Loss of Memory?*
Please provide details of your loss of memory
Do you suffer from Wandering?*
Please provide details of your wandering
Do you suffer from a Psychiatric Disability?*
Please provide details of your psychiatric disability
Do you suffer from a Intellectual Disability?*
Please provide details of your intellectual disability
Do you suffer from a Physical Disability?*
Please provide details of your physical disability
Do you suffer from Incontinence?*
Please provide details of your incontinence
Do you require assistance
- Dressing
- Showering
- Toileting
Do you have any other health Concerns? I.e. Diabetes, Pneumonia*
Please provide details of any other health concerns
Do you take any Medication?*
Please provide details of your medication

Case Worker Details
Do you have a Case Worker?*
Case Worker Name
First Last
Case Worker's Organisation
Case Worker Phone No.
Details of the person completing this application.
Who completed this application?*
Name
First Last
Phone
Email
Relationship to perspective resident?
Date Requiring Accommodation
Date requiring accommodation*

Interested in accommodation at Cotlew Manor?

Step 1 of 5

Applicant Details

Next of Kin Details

Pension Information

Medicare & Private Health Cover Information

Current Doctor Details

Substitute Decision Maker

Involuntary Treatment Order (ITO)

Allergies and Health Information

Case Worker Details

Details of the person completing this application.

Date Requiring Accommodation