Referrer details


(e.g. Registered Nurse, etc)





(office no. or mobile)

Type of Visit


 You need to indicate who has given consent to refer this recipient for the 
Aged Care Volunteer Visitors Scheme (ACVVS)


(e.g. family member, the recipient themselves, etc)
Recipients details (the person who will receive the visit)

(e.g. Mr, Ms, etc)









(e.g. Christian, Buddhist, etc)

(e.g. Greek, Cantonese, etc)

(e.g. "recipient's family moved interstate and can't visit regularly")

(e.g. "originally from Guangzhou province in China, immigrating to Australia in 1955...")

(e.g. "worked as a vet in country Victoria up until retirement in 1999...")

(e.g. "avid gardener, enjoy restoring classic Holden cars...")

(e.g. "a family member visits once a week...")

(e.g. "someone to watch Judge Judy with at 3pm...")


Health status
 This information is vitally important for ensuring visitor matching is appropriate.

(e.g. mobility, hearing, eyesight, continence, dementia, challenging behaviour, etc)
Special needs groups
 Note - we are required to ask this question by the Dept. of Social Services*. Information is strictly confidential, it is conveyed to Dept. of Health as anonymous data only.

*As specified under the Aged Care Act 1997
Visitor preferences

(e.g. "can speak Greek", "should have an understanding of Islamic traditions & etiquette" etc)
Home Care Package recipients only


Home address







Emergency contact


(e.g. brother, friend, carer)


(optional, but recommended)

Contact Information