About Hospital to Home The Summer Foundation is a not-for-profit organisation that exists to stop young people with disability being forced to live in aged care.
The Hospital to Home service supports the discharge of people with disability from hospital to housing that aligns with their housing needs and preferences. The approach is rights based, and incorporates principles of choice, control and inclusion for people with disability.
How to complete this form This form should be completed by a member of the supporting hospital team or NDIS support coordinator and the person being referred (or if appointed - their legal representative).
This form is made up of 3 parts.
Part A asks for the person's name and contact details. This part should be completed by the person being referred (or their legal representative).
Part B asks for health and NDIS information. This part should be completed by the supporting hospital team or the person's NDIS support coordinator.
Part C asks for consent and provides information about our Privacy Policy. This part should be completed by the person being referred (or their legal representative).
Person being referred
Person being referred
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Person being referred
Someone else
Person being referred
Someone else
Primary contact person name
*
Primary contact person phone
*
Primary contact person email
*
Has a legal guardian or decision-maker been appointed for you?
Yes Applying for guardianship No
Do you have a support coordinator?
Yes Funded but not engaged No
Is the person being referred as part of the Pathways to Home program?
(This program was previously called C19-TCP-D; If you are unsure, select no.)
*
Yes
No
Pathways to Home is a current Victorian Department of Health project
Is the person currently in hospital?
*
Yes
No
ACT NSW NT QLD SA TAS VIC WA
UR number / patient ID (if known)
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Is the person medically ready for discharge?
*
Yes No Unknown
When is the person expected to be medically ready for discharge?
Today D-M-Y
What date was the person medically ready for discharge?
Today D-M-Y
Describe what you see as the primary barriers to discharge
Acquired Brain Injury Amputation Autism spectrum disorder Cerebral palsy Chromosomal syndrome (e.g. Fragile X syndrome) Degenerative neurological disease (e.g. Alzheimers, Parkinson's) Developmental delay Down syndrome Genetic condition Global developmental delay Hearing impairment Huntington's disease Intellectual disability Multiple Sclerosis Other neurological condition Other physical disability Other sensory/speech Psychosocial disability Spinal cord injury Stroke (haemorrhagic) Stroke (ischaemic) Traumatic brain injury Visual impairment
Specify the degenerative neurological disease
e.g., Multiple Sclerosis, Huntington's disease
Specify the developmental disability
Specify the genetic condition
Specify the chromosomal syndrome
e.g., Down syndrome, Fragile X syndrome
Specify the neurological condition
Specify the spinal cord injury
e.g., T4, complete/incomplete
Specify the psychosocial disability
Specify the hearing impairment
Specify the visual impairment
Specify the physical disability
Specify the sensory disability
Yes
No
Secondary disabilities (please tick all that apply)
Please tick all that apply
Is the person an NDIS participant?
*
Yes No
Is the person likely to be an NDIS participant?
Yes No Unknown
What is the person's current NDIS status?
Awaiting access Awaiting first planning meeting Awaiting first plan approval Has NDIS plan without all necessary funding Awaiting plan review meeting Awaiting plan approval (not first plan) Awaiting outcome of request for plan review Has NDIS plan with all necessary funding Other Unknown
if other, please describe
Name, phone number, email, agency/institution
Name, phone number, email, agency/institution
Name, phone number, email, agency/institution
Name, phone number, email, agency/institution
Others (e.g. DLO, HLO, family)
Name, phone number, email, agency/institution
What support team member will act as primary contact?
Multiple names can be listed
Privacy Notice
Hospital to Home will work with you, your health team, your support coordinator and, if appointed, your guardian or any other third-party decision-maker, to support you to move out of hospital. Part of our job is to make sure everyone is talking to you about where you want to live, who you want to live with and how you want to live. We will then look for housing for you that meets as many of your needs and preferences as possible.
With your consent we will collect sensitive information about you, which may include health reports and plans, hospital discharge reports and summaries, your NDIS participant number, information about your NDIS status and eligibility, information about your individual support and accessibility needs, your family situation, and your past and current living situations. We are also collecting your personal information on this form.
We will use the information to search for housing for you. When we find a housing provider who might have a good housing option for you, we will share your personal information with them to make sure the housing option is suitable.
Your information will be stored, used and disclosed in accordance with the Summer Foundation Privacy Policy. For more information visit https://www.summerfoundation.org.au/home/privacy-policy/
If you have any questions about how we will use your information, we can explain it to you. If you have any questions about the Privacy Notice below, please email us on hospitaltohome@summerfoundation.org.au
Can the Summer Foundation ask relevant stakeholders and services for information about you?
*
Yes
No
e.g. support and housing providers, support coordinator, allied health professionals, hospital staff, support workers.
Can the Summer Foundation give information to relevant stakeholders and services about you?
*
Yes
No
e.g. support and housing providers, support coordinator, allied health professionals, hospital staff, support workers.
Are there any stakeholders, people or organisations that you DO NOT want the Summer Foundation to seek information from or share information with?
Write their names and organisation or relationship to you and the Summer Foundation will not speak to these people without asking you first:
Are there any family or friends the Summer Foundation should speak to about you and your housing search?
Please write the name, their relationship to you, and contact details of family and friends we should speak to.
If we need to speak to you, can we contact you?
*
Yes
No
The Summer Foundation does important research to better understand: The housing needs of people with disability The effect that quality housing has on the lives of people with disability and, How the hospital discharge process can be improved to meet these needs The research is a really important part of solving the problem of younger people with disability being forced to live in aged care.
Can the Summer Foundation contact you in future to ask you about your life, your housing and your hospital discharge experience?
*
Yes
No
Can the Summer Foundation use de-identified data collected as part of our work with you in research?
*
Yes
No
I understand this form and I can sign my own name
I understand this form, but I cannot sign my name. I consent to this form being signed on my behalf
I understand this form and I am the legal representative of the person
I understand this form and I can sign my own name
I understand this form, but I cannot sign my name. I consent to this form being signed on my behalf
I understand this form and I am the legal representative of the person
E.g., Guardian, social worker, support coordinator
Full name of person signing
*
Today D-M-Y
Submit
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