Carer Payment and/or Carer Allowance: Caring for a person 16 years or over Instructions

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This form contains 186 fields organized into 46 sections. Below is a complete list of every field, its type, and what information is expected.

Field Name Type Description
Applicant Details
Title Text
Please enter your title, such as Mr, Mrs, Miss, Ms, or Dr.
Max length: 19 characters
Family Name Text
Please enter your family name.
Max length: 48 characters
First Given Name Text
Please enter your first given name.
Max length: 48 characters
Other Given Name(s) Text
Please enter any other given names you may have.
Max length: 48 characters
Month of Birth Text
Please enter the month of your birth.
Max length: 4 characters
Year of Birth Number
Please enter the year of your birth.
Max length: 6 characters
Male Checkbox
Check this box if the applicant's gender is Male.
Female Checkbox
Check this box if the applicant's gender is Female.
Other Checkbox
Check this box if the applicant's gender is not Male or Female.
Phone Number Part 2 Text
Please enter the second part of your contact phone number.
Max length: 40 characters
Phone Number Part 1 Text
Please enter the first part of your contact phone number.
Max length: 4 characters
checkbox_8dc6_deee CheckBox
Day of Birth Text
Please enter the day of your birth.
Max length: 3 characters
Daily Care Provision Details
Care Start Day Text
Please enter the day the care started. Fill only if 'Yes' is 'Yes'.
Max length: 3 characters
Depends on: Yes
No Checkbox
Check this box if you do not personally provide daily care for your partner due to their disability or medical condition. Fill only if 'List condition(s)' is filled
Depends on: Partner's Medical Conditions
Yes Checkbox
Check this box if you personally provide daily care for your partner due to their disability or medical condition. Fill only if 'List condition(s)' is filled
Depends on: Partner's Medical Conditions
text_INGhgl_cd6d Text
Max length: 6 characters
Depends on: Yes
Care Start Month Text
Please enter the month the care started. Fill only if 'Yes' is 'Yes'.
Max length: 3 characters
Depends on: Yes
Damage furniture, possessions or objects
Never Checkbox
Check this box if your partner never damages furniture, possessions, or objects. Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'No'.
Depends on: No
Sometimes Checkbox
Check this box if your partner sometimes damages furniture, possessions, or objects. Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'No'.
Depends on: No
Often Checkbox
Check this box if your partner often damages furniture, possessions, or objects. Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'No'.
Depends on: No
Date of Hospitalisation
Hospitalisation Day Text
Please enter the day your partner was admitted to the hospital. Fill only if 'Partner in Hospital (Yes)' is 'Yes'.
Max length: 3 characters
Depends on: Partner in Hospital (Yes)
Hospitalisation Month Text
Please enter the month your partner was admitted to the hospital. Fill only if 'Partner in Hospital (Yes)' is 'Yes'.
Max length: 5 characters
Depends on: Partner in Hospital (Yes)
Hospitalisation Year Text
Please enter the year your partner was admitted to the hospital. Fill only if 'Partner in Hospital (Yes)' is 'Yes'.
Max length: 6 characters
Depends on: Partner in Hospital (Yes)
Deliberately harm themselves
Never Checkbox
Check this box if your partner never deliberately harms themselves. Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'No'.
Depends on: No
Sometimes Checkbox
Check this box if your partner sometimes deliberately harms themselves. Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'No'.
Depends on: No
Often Checkbox
Check this box if your partner often deliberately harms themselves. Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'No'.
Depends on: No
Dressing
checkbox_6NjiOr_c02b CheckBox
checkbox_ozeHjI_7646 CheckBox
checkbox_b5OuQj_47c6 CheckBox
checkbox_skDYWR_78b9 CheckBox
Eating Food
Without help Checkbox
Check this box if the person can eat their food without any assistance. Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'No'.
Depends on: No
With some help Checkbox
Check this box if the person requires some assistance to eat their food. Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'No'.
Depends on: No
With a lot of help Checkbox
Check this box if the person requires significant assistance to eat their food. Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'No'.
Depends on: No
Cannot feed themselves Checkbox
Check this box if the person is completely unable to feed themselves. Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'No'.
Depends on: No
Expected Hospital Release Date
Expected Release Date - Day Text
Please provide the day of your partner's expected hospital release. Fill only if 'Partner in Hospital (Yes)' is 'Yes'.
Max length: 3 characters
Depends on: Partner in Hospital (Yes)
Expected Release Date - Year Text
Please provide the year of your partner's expected hospital release. Fill only if 'Partner in Hospital (Yes)' is 'Yes'.
Max length: 6 characters
Depends on: Partner in Hospital (Yes)
Expected Release Date - Month Text
Please provide the month of your partner's expected hospital release. Fill only if 'Partner in Hospital (Yes)' is 'Yes'.
Max length: 3 characters
Depends on: Partner in Hospital (Yes)
General
text_91a8_eb9b Text
Max length: 48 characters
text_faaa_b413 Text
Max length: 48 characters
text_c748_5289 Text
Max length: 48 characters
text_4d1a_27cc Text
Max length: 48 characters
text_fpyd3e_c40c Text
Max length: 58 characters
text_acxqYm_9700 Text
Max length: 58 characters
text_MIEsE4_06b1 Text
Max length: 58 characters
Hospitalization Status
Partner in Hospital (Yes) Checkbox
Check this box if your partner is currently admitted to a hospital.
Partner in Hospital (No) Checkbox
Check this box if your partner is not currently admitted to a hospital.
In-Hospital Care Provision
Care Provided During Hospitalization Text
Please describe the specific care you provide for your partner while they are hospitalized, such as involvement in rehabilitation or treatment. Fill only if 'Yes, I provide care' is 'Yes'.
Depends on: Yes, I provide care
Yes, I provide care Checkbox
Check this box if you provide care for your partner while they are in the hospital, for example, by being involved in their rehabilitation or treatment. Fill only if 'Partner in Hospital (Yes)' is 'Yes'.
Depends on: Partner in Hospital (Yes)
No, I do not provide care Checkbox
Check this box if you do not provide care for your partner while they are in the hospital. Fill only if 'Partner in Hospital (Yes)' is 'Yes'.
Depends on: Partner in Hospital (Yes)
Laugh or cry without apparent reason
Never Checkbox
Check this box if your partner never laughs or cries without apparent reason. Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'No'.
Depends on: No
Sometimes Checkbox
Check this box if your partner sometimes laughs or cries without apparent reason. Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'No'.
Depends on: No
Often Checkbox
Check this box if your partner often laughs or cries without apparent reason. Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'No'.
Depends on: No
Loss of Bladder/Bowel Control
Always Checkbox
Check this box if the partner always experiences loss of bladder and/or bowel control. Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'No'.
Depends on: No
Often Checkbox
Check this box if the partner often experiences loss of bladder and/or bowel control. Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'No'.
Depends on: No
Sometimes Checkbox
Check this box if the partner sometimes experiences loss of bladder and/or bowel control. Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'No'.
Depends on: No
Never Checkbox
Check this box if the partner never experiences loss of bladder and/or bowel control. Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'No'.
Depends on: No
Overnight Stay Regularity
Yes Checkbox
Check this box if your partner stays overnight or longer with any other person or organisation on a regular basis.
No Checkbox
Check this box if your partner does not stay overnight or longer with any other person or organisation on a regular basis.
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Year Date
Enter the year of the signature date. Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'Yes'.
Max length: 6 characters
Depends on: Yes
Day Date
Enter the day of the signature date. Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'Yes'.
Max length: 3 characters
Depends on: Yes
Month Date
Enter the month of the signature date. Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'Yes'.
Max length: 3 characters
Depends on: Yes
Signature Text
Enter your full legal signature here. Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'Yes'.
Max length: 48 characters
Depends on: Yes
Partner Details
Partner's Title Text
Enter your partner's title, such as Mr, Mrs, Miss, Ms, Dr, or any other relevant title.
Max length: 19 characters
Partner's Family Name Text
Enter your partner's family name (surname).
Max length: 48 characters
Partner's First Given Name Text
Enter your partner's first given name.
Max length: 49 characters
Partner's Other Given Name(s) Text
Enter any other given names your partner may have, if applicable.
Max length: 48 characters
Partner's Month of Birth Date
Enter the month of your partner's birth.
Max length: 4 characters
Partner's Year of Birth Date
Enter the year of your partner's birth.
Max length: 6 characters
Male (Partner) Checkbox
Check this box if your partner's gender is Male.
Female (Partner) Checkbox
Check this box if your partner's gender is Female.
Other (Partner Gender) Checkbox
Check this box if your partner's gender is not Male or Female.
Partner's Day of Birth Date
Enter the day of your partner's birth.
Max length: 3 characters
Partner's Ability to Communicate Needs
checkbox_WMk03g_54ca CheckBox
checkbox_4m13eU_ce83 CheckBox
checkbox_rWJDYh_93ea CheckBox
checkbox_74k19w_c733 CheckBox
Partner's ability to move around the house
Without help Checkbox
Check this box if your partner can move around the house independently, possibly using aids such as a walking stick, frame, or wheelchair. Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'No'.
Depends on: No
With help of one person Checkbox
Check this box if your partner needs the assistance of one person to move around the house. Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'No'.
Depends on: No
With help of two people Checkbox
Check this box if your partner requires the assistance of two people to move around the house. Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'No'.
Depends on: No
Is confined to bed Checkbox
Check this box if your partner is unable to move around the house and is confined to bed. Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'No'.
Depends on: No
Partner's ability to move to and from furniture and aids
Without help Checkbox
Check this box if your partner can move to and from bed, chairs, wheelchair, and walking aids without any assistance or supervision. Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'No'.
Depends on: No
Cannot do this Checkbox
Check this box if your partner is unable to move to and from bed, chairs, wheelchair, and walking aids, even with help. Fill only if 'Is confined to bed' is selected.
Depends on: Is confined to bed
With a lot of help Checkbox
Check this box if your partner needs a significant amount of physical assistance, guidance, or supervision to move to and from bed, chairs, wheelchair, and walking aids. Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'No'.
Depends on: No
With some help Checkbox
Check this box if your partner needs some physical assistance, guidance, or supervision to move to and from bed, chairs, wheelchair, and walking aids. Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'No'.
Depends on: No
Partner's Awareness of Location
Always Checkbox
Check this box if your partner always knows where they are. Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'No'.
Depends on: No
Usually Checkbox
Check this box if your partner usually knows where they are. Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'No'.
Depends on: No
Sometimes Checkbox
Check this box if your partner sometimes knows where they are. Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'No'.
Depends on: No
Never Checkbox
Check this box if your partner never knows where they are. Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'No'.
Depends on: No
Partner's Awareness of Time of Day
Always Checkbox
Check this box if the partner is always aware of whether it is morning, afternoon, or night. Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'No'.
Depends on: No
Usually Checkbox
Check this box if the partner is usually aware of whether it is morning, afternoon, or night. Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'No'.
Depends on: No
Sometimes Checkbox
Check this box if the partner is sometimes aware of whether it is morning, afternoon, or night. Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'No'.
Depends on: No
Never Checkbox
Check this box if the partner is never aware of whether it is morning, afternoon, or night. Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'No'.
Depends on: No
Partner's difficulty hearing
Never Checkbox
Check this box if your partner never has difficulty hearing others, even when using hearing aids. Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'No'.
Depends on: No
Sometimes Checkbox
Check this box if your partner sometimes has difficulty hearing others, even when using hearing aids. Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'No'.
Depends on: No
Often Checkbox
Check this box if your partner often has difficulty hearing others, even when using hearing aids. Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'No'.
Depends on: No
Always Checkbox
Check this box if your partner always has difficulty hearing others, even when using hearing aids. Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'No'.
Depends on: No
Partner's difficulty seeing
Always Checkbox
Check this box if your partner always has difficulty seeing clearly, even with glasses. Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'No'.
Depends on: No
Often Checkbox
Check this box if your partner often has difficulty seeing clearly, even with glasses. Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'No'.
Depends on: No
Sometimes Checkbox
Check this box if your partner sometimes has difficulty seeing clearly, even with glasses. Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'No'.
Depends on: No
Never Checkbox
Check this box if your partner never has difficulty seeing clearly, even with glasses. Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'No'.
Depends on: No
Partner's frequency of falling
Often Checkbox
Check this box if your partner often falls over indoors or outdoors (or from a wheelchair). Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'No'.
Depends on: No
Sometimes Checkbox
Check this box if your partner sometimes falls over indoors or outdoors (or from a wheelchair). Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'No'.
Depends on: No
Never Checkbox
Check this box if your partner never falls over indoors or outdoors (or from a wheelchair). Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'No'.
Depends on: No
Partner's Grooming
Grooming: Without help Checkbox
Check this box if your partner can look after their grooming completely without any help. Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'No'.
Depends on: No
Grooming: With some help Checkbox
Check this box if your partner needs some assistance to look after their grooming. Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'No'.
Depends on: No
Grooming: With a lot of help Checkbox
Check this box if your partner requires a lot of assistance to look after their grooming. Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'No'.
Depends on: No
Grooming: Cannot do this Checkbox
Check this box if your partner is unable to look after their grooming at all. Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'No'.
Depends on: No
Partner's Medical Condition
Partner's Medical Conditions Text
Provide a detailed list of your partner's main disability or medical conditions for which they require care.
Partner's Medication
Without help Checkbox
Check this box if your partner is able to take their own medication completely without any assistance. Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'No'.
Depends on: No
With some help Checkbox
Check this box if your partner requires some assistance to take their own medication. Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'No'.
Depends on: No
With a lot of help Checkbox
Check this box if your partner requires significant assistance to take their own medication. Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'No'.
Depends on: No
Cannot do this Checkbox
Check this box if your partner is unable to take their own medication, even with help. Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'No'.
Depends on: No
Does not take medication Checkbox
Check this box if your partner does not take any medication at all. Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'No'.
Depends on: No
Partner's need for help at night
Never Checkbox
Check this box if your partner never needs help or attention during the night. Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'No'.
Depends on: No
Sometimes Checkbox
Check this box if your partner sometimes needs help or attention during the night. Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'No'.
Depends on: No
Often Checkbox
Check this box if your partner often needs help or attention during the night. Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'No'.
Depends on: No
Always Checkbox
Check this box if your partner always needs help or attention during the night. Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'No'.
Depends on: No
Partner's Short-Term Memory
Always Checkbox
Check this box if your partner always remembers things that happened today. Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'No'.
Depends on: No
Usually Checkbox
Check this box if your partner usually remembers things that happened today. Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'No'.
Depends on: No
Sometimes Checkbox
Check this box if your partner sometimes remembers things that happened today. Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'No'.
Depends on: No
Never Checkbox
Check this box if your partner never remembers things that happened today. Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'No'.
Depends on: No
Partner's Treatment
Without help Checkbox
Check this box if the partner can take care of their own treatment entirely independently. Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'No'.
Depends on: No
With some help Checkbox
Check this box if the partner needs some assistance to take care of their own treatment. Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'No'.
Depends on: No
With a lot of help Checkbox
Check this box if the partner requires significant assistance to take care of their own treatment. Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'No'.
Depends on: No
Cannot do this Checkbox
Check this box if the partner is completely unable to take care of their own treatment. Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'No'.
Depends on: No
Does not have treatment Checkbox
Check this box if the partner is not currently undergoing any treatment. Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'No'.
Depends on: No
Partner's Understanding of Carer
Always Checkbox
Check this box if your partner always understands what you, the carer, say. Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'No'.
Depends on: No
Usually Checkbox
Check this box if your partner usually understands what you, the carer, say. Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'No'.
Depends on: No
Sometimes Checkbox
Check this box if your partner sometimes understands what you, the carer, say. Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'No'.
Depends on: No
Never Checkbox
Check this box if your partner never understands what you, the carer, say. Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'No'.
Depends on: No
Partner's Understanding of Others
Always Checkbox
Check this box if your partner always understands what other people say. Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'No'.
Depends on: No
Usually Checkbox
Check this box if your partner usually understands what other people say. Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'No'.
Depends on: No
Sometimes Checkbox
Check this box if your partner sometimes understands what other people say. Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'No'.
Depends on: No
Never Checkbox
Check this box if your partner never understands what other people say. Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'No'.
Depends on: No
Physically harm other people
Never Checkbox
Check this box if your partner never physically harms other people. Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'No'.
Depends on: No
Sometimes Checkbox
Check this box if your partner sometimes physically harms other people. Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'No'.
Depends on: No
Often Checkbox
Check this box if your partner often physically harms other people. Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'No'.
Depends on: No
Post-Hospital Care Status
No Checkbox
Check this box if your partner will NOT return to your care after being released from the hospital. Fill only if 'Partner in Hospital (Yes)' is 'Yes'.
Depends on: Partner in Hospital (Yes)
Yes Checkbox
Check this box if your partner WILL return to your care after being released from the hospital. Fill only if 'Partner in Hospital (Yes)' is 'Yes'.
Depends on: Partner in Hospital (Yes)
Reason for Stay: Education/Training
Education/Training Start Year Number
Enter the year when your partner's overnight stays for education or training began. Fill only if 'Education/training' is selected.
Max length: 6 characters
Depends on: Education/training
Education/Training Start Day Text
Enter the day of the month when your partner's overnight stays for education or training began. Fill only if 'Education/training' is selected.
Max length: 3 characters
Depends on: Education/training
Education/Training Start Month Text
Enter the month when your partner's overnight stays for education or training began. Fill only if 'Education/training' is selected.
Max length: 3 characters
Depends on: Education/training
Education/Training Nights Number
Enter the total number of nights your partner stays overnight for education or training. Fill only if 'Education/training' is selected.
Max length: 30 characters
Depends on: Education/training
Education/training Checkbox
Check this box if your partner stays overnight for education or training, such as at a training centre or hostel. Fill only if 'Yes' is 'Yes'.
Depends on: Yes
Reason for Stay: Other Care
Start Date Year Text
Enter the year when 'Other care' started. Fill only if 'Other care' is selected.
Max length: 6 characters
Depends on: Other care
Start Date Day Text
Enter the day of the month when 'Other care' started. Fill only if 'Other care' is selected.
Max length: 3 characters
Depends on: Other care
Start Date Month Text
Enter the month when 'Other care' started. Fill only if 'Other care' is selected.
Max length: 3 characters
Depends on: Other care
Number of Nights Text
Enter the number of nights your partner stays overnight for 'Other care'. Fill only if 'Other care' is selected.
Max length: 30 characters
Depends on: Other care
Other care Checkbox
Check this box if your partner stays overnight or longer due to temporary care, spending nights with another person not living with you, or respite care. Fill only if 'Yes' is 'Yes'.
Depends on: Yes
Reason for Stay: Shared Care
Start Date Year Text
Enter the year the shared care started. Fill only if 'Shared care' is selected.
Max length: 6 characters
Depends on: Shared care
Start Date Day Text
Enter the day the shared care started. Fill only if 'Shared care' is selected.
Max length: 3 characters
Depends on: Shared care
Start Date Month Text
Enter the month the shared care started. Fill only if 'Shared care' is selected.
Max length: 3 characters
Depends on: Shared care
Number of Nights Text
Enter the total number of nights the partner stays for shared care. Fill only if 'Shared care' is selected.
Max length: 30 characters
Depends on: Shared care
Shared care Checkbox
Check this box if your partner stays overnight for shared care, for example, with another family member. Fill only if 'Yes' is 'Yes'.
Depends on: Yes
Reason for Stay: Treatment
Treatment Start Year Text
Enter the year the treatment stay began. Fill only if 'Treatment (other than hospitalisation)' is selected.
Max length: 6 characters
Depends on: Treatment (other than hospitalisation)
Treatment Start Month Text
Enter the month the treatment stay began. Fill only if 'Treatment (other than hospitalisation)' is selected.
Max length: 3 characters
Depends on: Treatment (other than hospitalisation)
Treatment Start Day Text
Enter the day the treatment stay began. Fill only if 'Treatment (other than hospitalisation)' is selected.
Max length: 3 characters
Depends on: Treatment (other than hospitalisation)
Number of Treatment Nights Text
Enter the number of nights your partner stays for treatment. Fill only if 'Treatment (other than hospitalisation)' is selected.
Max length: 30 characters
Depends on: Treatment (other than hospitalisation)
Treatment (other than hospitalisation) Checkbox
Check this box if your partner stays overnight or longer with another person or organisation on a regular basis for treatment, excluding hospitalisation, such as spending nights at therapy. Fill only if 'Yes' is 'Yes'.
Depends on: Yes
Shout, scream at or threaten other people
Never Checkbox
Check this box if your partner never shouts, screams at, or threatens other people. Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'No'.
Depends on: No
Sometimes Checkbox
Check this box if your partner sometimes shouts, screams at, or threatens other people. Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'No'.
Depends on: No
Often Checkbox
Check this box if your partner often shouts, screams at, or threatens other people. Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'No'.
Depends on: No
Showering/Bathing
Without help Checkbox
Check this box if the person can shower or bath themselves without any assistance. Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'No'.
Depends on: No
With some help Checkbox
Check this box if the person requires some assistance to shower or bath themselves. Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'No'.
Depends on: No
With a lot of help Checkbox
Check this box if the person requires a significant amount of assistance to shower or bath themselves. Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'No'.
Depends on: No
Cannot do this Checkbox
Check this box if the person is unable to shower or bath themselves even with assistance. Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'No'.
Depends on: No
Terminal Illness Status
No Checkbox
Check this box if your partner is NOT terminally ill or is expected to live for more than 3 months.
Yes Checkbox
Check this box if your partner IS terminally ill and IS expected to live for 3 months or less.
Toilet Use
Without help Checkbox
Check this box if the person can use the toilet completely independently, without any assistance. Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'No'.
Depends on: No
With some help Checkbox
Check this box if the person requires some assistance to use the toilet. Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'No'.
Depends on: No
With a lot of help Checkbox
Check this box if the person requires significant assistance to use the toilet. Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'No'.
Depends on: No
Cannot use a toilet Checkbox
Check this box if the person is unable to use a toilet, even with assistance. Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'No'.
Depends on: No
Unusual, inappropriate or repetitive behaviours
Never Checkbox
Check this box if your partner never exhibits unusual, inappropriate, or repetitive behaviours. Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'No'.
Depends on: No
Sometimes Checkbox
Check this box if your partner sometimes exhibits unusual, inappropriate, or repetitive behaviours. Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'No'.
Depends on: No
Often Checkbox
Check this box if your partner often exhibits unusual, inappropriate, or repetitive behaviours. Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'No'.
Depends on: No
Use of Continence Aids/Equipment
Without help Checkbox
Check this box if the person uses continence aids or equipment entirely independently, without any assistance. Fill only if 'Always', 'Often', 'Sometimes' is selected, any.
Depends on: Always, Often, Sometimes
With some help Checkbox
Check this box if the person uses continence aids or equipment but requires some assistance from others. Fill only if 'Always', 'Often', 'Sometimes' is selected, any.
Depends on: Always, Often, Sometimes
With a lot of help Checkbox
Check this box if the person uses continence aids or equipment but requires significant assistance from others. Fill only if 'Always', 'Often', 'Sometimes' is selected, any.
Depends on: Always, Often, Sometimes
Does not use aids Checkbox
Check this box if the person does not use any continence aids or equipment. Fill only if 'Always', 'Often', 'Sometimes' is selected, any.
Depends on: Always, Often, Sometimes
Wander away or 'run away' from home
Never Checkbox
Check this box if your partner never wanders away or 'runs away' from home. Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'No'.
Depends on: No
Sometimes Checkbox
Check this box if your partner sometimes wanders away or 'runs away' from home. Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'No'.
Depends on: No
Often Checkbox
Check this box if your partner often wanders away or 'runs away' from home. Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'No'.
Depends on: No
Withdraw from contact with other people
Never Checkbox
Check this box if your partner never withdraws from contact with other people, or never appears depressed, worried or fearful. Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'No'.
Depends on: No
Sometimes Checkbox
Check this box if your partner sometimes withdraws from contact with other people, or sometimes appears depressed, worried or fearful. Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'No'.
Depends on: No
Often Checkbox
Check this box if your partner often withdraws from contact with other people, or often appears depressed, worried or fearful. Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'No'.
Depends on: No