program_name

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Get support at home with confidence

Whether you're planning ahead, waiting for funding or ready to start services, our team can help you understand your options.

You don't need to know exactly what services you need or how funding works. Our team will talk through your situation, answer your questions and help you understand what options and next steps are available to you.

Please complete the form below and we'll be in touch.

Takes about 2 minutes.

Please complete all fields marked with an asterisk (*). Required fields must be completed before the form can be submitted.

Who are you looking for support for?

I am: *

Looking for support for myselfHelping someone else find support (family member, friend) I am a health professional or service referring someone

About the person looking for support

First name *

Last name *

Date of birth *

Mobile Phone *

Landline If providing a landline number, please include the area code, for example: 0712345678.

Email *

Address *

Street address *Street address line 2

City *

State *

Postcode *

Primary contact

Who should we contact about this enquiry? *

The person needing supportTheir family member, carer or representativeEither person

A representative or support person may be a family member, carer, authorised representative or another person helping with the enquiry

Representatives Details

First name *

Last name *

Phone number *

Email *

Relationship to person needing support *

Funding and situation

Do you know how the support will be funded? *

Support at Home (previously Home Care Package)Commonwealth Home Support Programme (CHSP)Self-fundedNot sure

Which of the following best describes the current situation? *

Just exploring optionsWould like help understanding eligibility and fundingWaiting for assessment or funding approvalFunding approved and ready to start servicesCurrently receiving services and considering a new providerNot sure

Additional information

Is there anything you'd like our team to know before we contact you? For example, tell us about the support you're looking for, what's important to you, or any communication, accessibility or interpreter needs.

How would you prefer us to contact you?

Mobile phoneLandlineEmail

When is the best time to contact you?

MorningAfternoonEvening

Is there anything else you'd like us to know?For example, communication or accessibility needs, interpreter requirements, or other information that may help us support the person.

Preferred contact method

Mobile phoneLandlineEmail

Best time to contact

MorningAfternoonEvening

Referrer details

Referrer name *

Role *

Organisation or service *

Email *

Phone number *

How did you find out about us?

Other

Name of event

Name of clinic

Name of channel

Name of team

Amplar Health program name

Consent

I’d like to receive updates, information and content about health programs and services that may be relevant to me. I agree that Amplar Health may use my personal (including health) information to personalise the information I receive. Amplar Health may contact me by email, SMS, phone or other channels (optional).

I agree to Amplar Health collecting and using the information provided in this form, including information about the person requiring support and any nominated representative, family member, carer or contact person, for the purpose of responding to this enquiry and discussing suitable support options. For more information about how we collect, use and protect personal information, please see our Privacy Policy.

*

I confirm the person has agreed to Amplar Health collecting and using the information provided in this form, includinginformation about the person requiring support and any nominatedrepresentative, family member, carer or contact person, for the purpose ofresponding to this enquiry and discussing suitable support options. For moreinformation about how we collect, use and protect personal information, pleasesee our PrivacyPolicy. *

1300 725 561

agebetter@amplarhealth.com.au

amplarhealth.com.au