Application for voluntary admission to a mental health care facility / group home / relief care (revised july 2014)

To help you understand the process: There will be two non profit entities involved in your application process. The first assessment will be done by our multi disciplinary team from Community Mental Health & Psychiatry (CMHP). The second asessment will be done by a Financial Counsellor from the Help Your Neighbour Fund (HYN).

Information of service user / patient / client

Surname:   ID Number:
Full Names:   Sex:
Address:   Highest qualification:
Cell:   Occupation before
retirement or disability:
Email:    
Email to receive Copy:      

Information of service user / patient / client

What is your Psychiatric Diagnosis?   List all medication currently administered to you:
When were you first diagnosed?  
How many admissions have you had to a psychiatric hospital?   Any additional information you need to bring to our attention
Date and length of latest admission:   At which hospital and/or clinic, did or do you receive:
In-patient treatment:   Out-patient treatment:

Please tick relevant box *(Subject to availability)

 

What is your current accommodation situation? (tick one) How many of the following types of accommodation are you willing to live in? (Subject to availability and assessment)

 

Please tick relevant box

How many of the following are you able to do for yourself? Income of Service User / Patient: (A full financial asessment will be done by our Financial Counsellor)

Administer own medication:






Administer own money:

Take care of personal hygiene:

Cook food:

Marital Status

Clean room:

 

*If married, does your spouse have a mental illness?
 
 

Wash & iron clothes:

Tidy the home:

Accommodation

Do you need assistance with accommodation  

*



   

Are you willing to be accommodated in all of the following: Tick all those options you are willing to live in. If all options are not ticked it may cause a longer waiting period for admission.



 


 
Which means of transport can you use independantly:



 

 

Information

What do you do during the day?  









   
Do you suffer from the following conditions:  








:

Contact

Contact person / senior nurse at clinic acquainted with you:
   
   

 

Next of kin: List ALL children, parents and siblings:

Next of kin 1:

 

Next of kin 2:

Relation:   Relation:
Full Name:   Full Name:
Tel ( HOME ):   Tel ( HOME ):
Tel ( WORK ):   Tel ( WORK ):
Cell:   Cell:
Email:   Email:
Physical Address:   Physical Address:
Postal Address:   Postal Address:

Next of kin 3:

 

Next of kin 4:

Relation:   Relation:
Full Name:   Full Name:
Tel ( HOME ):   Tel ( HOME ):
Tel ( WORK ):   Tel ( WORK ):
Cell:   Cell:
Email:   Email:
Physical Address:   Physical Address:
Postal Address:   Postal Address:

Next of kin 5:

 

Next of kin 6:

Relation:   Relation:
Full Name:   Full Name:
Tel ( HOME ):   Tel ( HOME ):
Tel ( WORK ):   Tel ( WORK ):
Cell:   Cell:
Email:   Email:
Physical Address:   Physical Address:
Postal Address:   Postal Address:

Next of kin 7:

 

Next of kin 8:

Relation:   Relation:
Full Name:   Full Name:
Tel ( HOME ):   Tel ( HOME ):
Tel ( WORK ):   Tel ( WORK ):
Cell:   Cell:
Email:   Email:
Physical Address:   Physical Address:
Postal Address:   Postal Address:

 

Finances

Note: No application will be considered if incomplete. Each applicant must have a "responsible person / payer" who will take responsibillity for the payment of accounts and expenses. In the case of family members joining together to cover accounts, one person must be nominated and appointed by them as the responsible person / payer. In the case of an application submitted by any institution, trust or curator the concerned official applying on behalf of the client, should involve the most responsible next of kin in the application process, and must co-sign as responsible person / payer. If the official, after thorough investigation, is convinced that there are no next of kin of any sort, written adduce proof in support of, and a sworn affidavit to the effect must accompany this application.
Details of Responsible Person for paying (or details of Trust Contact Person)
   
Income of Responsible Person (In the case of parents, indicate total of both)



Please note: proof and information regarding fully disclosed assets and income in any form or any amount acrued to you or your spouse, directly or indirectly now or perhaps in future, whether it be immovable or movable property, investments, bequests, trusts, gifts, policies, pensions, interest, grants or alike, and whether you receive it or not, must be provided by means of:

(1) 3 months bank statements of responsible person (in the case of parents, both),
(2) Affidavit and minutes of meetings (if administered by family, friends, an institution or legal appointed person(s), or curator.
(3) Documents relating to investments, trusts, will, curatorship of the client.

Note: once your application has been submitted, you will be contacted by a Financial Counsellor from the Help Your Neighbour Fund to arrange for the necessary documents required as stated above. Please have these at hand as the application cannot be processed without these doucments.
How much do you currently spend on board & lodging including 3 meals per day




 

Please Note!

What financial arrangements have been made by the responsible person (parents etc.) in terms of bequests, trusts etc. after their death to ensure continuity and security for the service user / patient? * Please provide all relevant documentation:



I / we the undersigned (full names), Note: Electronic submitted versions will be signed by all concerned parties on the date of first interview.

declare in my / our capacity as (relation to client)

that I / we:

(1) Have disclosed all information regarding the applicant/client/patient (as refered to by name on page 1 of this application, and hereafter refered to as "the client") as well as the responsible person / payer by means of documents and sworn affidavits. Note: Once your application has been submitted, you will be contacted by a Financial Cousellor From the Help Your Neighbour Fund to arrange for the necessary documents required as stated above. Please have these at hand as the Application cannot be processed without these doucments.

(2) Understand that I / we remain responsible for the client and all accounts and expenses of the client.

(3) The family and / or responsible person will arrange with the facility manager, at leat 20 days in advance, to take the client out of the facility for a minimum of two weeks over the Christmas / New Year period in December. These two weeks will not be discounted for the month of December. Should the family fail to adhere to this clause, HYN will charge an additional pro rata fee to the said account, based on the maximum fee linked to the facility, for 14 days. This amount will reflect on the account and will be payable immediately.

(4) Two calender month written notice must be given to cancel lodging and or services rendered. Should the client vacate his / her room before the two months have lapsed, the payer will remain responsible for the remaining period of the two months. By death of client, the payer will remain responsible for the current month's rent.

(5) Should the client become ill or pass away, we commit ourselves to any reasonable requests from CMHP staff, i.e. arranging for transport to and from clinics and hospitals, including arrangements containing the removal of the body and arranging the funeral in the event of death.

(6) Should the client's application be successful, he / she will be on a probation period for 6 months. Should the client be discharged in the probation period I / we will make the necessary arrangements to send for the client within 24 hours.

(7) The client and / or responsible person or payer will be held responsible for any form of damage caused by the resident.

(8) Notify the organisation in writing at their Head Office of any changes or amendments to this document and specifically the attachments to this document, addresses, telephone numbers, and any change in financial abillities (ASSETS AND INCOME IN ANY FORM OR ANY AMOUNT ACRUED TO THE CLIENT OR HIS / HER SPOUSE, DIRECTLY OR INDIRECTLY NOW OR PERHAPS IN FUTURE, WHETHER IT BE MOVABLE OR IMMOVABLE PROPERTY, INVESTMENTS, BEQUESTS, TRUSTS, GIFTS, POLICIES, PENSIONS, INTEREST, GRANTS OR ALIKE, AND WHETHER THE CLIENT RECEIVES IT OR NOT)

(9) Understand that after submitting a fully completed application as required, including all relevant statements and affidavits, the client's monthly rent and /or board and lodging fees will be determined by a Financial Counsellor from The Help Your Neighour Fund, and that the client and payer will be informed in writing.

(10) The client may be put on a waiting list according to availability of beds/rooms.

(11) Before admission of the client can take place, and after I / we have received a written letter to the effect that the application was successful, and a Payment Plan was agreed upon and signed, I / we will deposit per electronic transfer, the non-refundable fees for the first month, payable in advance as set out in the Payment Plan.

(12) I / we undertake to provide the relevant facility manager with a Letter of Admission, as issued to me. Admission will not take place without the said.

(13) Should application for any form of pension (old age or disabillity pension), subsidy, maintenance or grants of any kind need to be made, CMHP will not admit the client unless written proof to the effect that an application for the said has been lodged with the appropriate department / body / institution or individual.

(14) The client and / or responsible person will remain responsible for the full account, where an application for pension, grant etc. is still pending.

(15) The client and / or responsible person will remain responsible for payment of accounts should the department / institution for whatever reason temporarily suspend or discontinue payment.

(16) On signature of this (A) Application for Admission and successful assessment by our Community Mental Health & Psychiatry (CMHP) multi disciplinery team and (B) Financial assessment by the Financial Counsellor from the Help Your Neighbour Fund (HYN) and agreement by all relative parties, a legal Agreement is constituted, and all stipulations, attachments and information attained will become part of this Agreement.

(17) Should I / we not comply to the stipulations of this Agreement, and should at a later stage it be discovered that information especially regarding the assets and income submitted with this application proves to be incorrect or false, or accounts be in arrears, I / we agree to CMHP and / or HYN or it's covering body to attain legal advice. I understand that the client and / or responsible person will be held responsible for all legal costs and debt recovery on an attorney-client-scale.

(18) On moral grounds (especially in the case of parents applying for children or children applying for parents) I / we will make ample provision in my will / estate for the life-long care and expenses of the client. This can be done in the form of a trust for the client or a bequest to the Help Your Neigbour Fund. I / we understand that I / we can negotiate a lumpsum single amount payment to CMHP represented by the Financial Counsellor from the Help Your Neighbour Fund, to guarantee life-long care to the client including a reduced rent / board and lodging.

(19) No amendment, exceptions, discount or compensation of any kind made or offered by any staff member of CMHP or HYN will be valid or binding, unless made by the CEO or Founder as per an official signed letter of which I / we will have the original in my possession.

Method Of Payment

(1) CASH: No CASH will be accepted whatsoever.

(2) BANK DEPOSIT: Cash, cheques, bank and electronic transferes can be made to the account of the Help Your Neighbour Fund. The payment will only be deemed as payed once the payment has cleared and the proof of payment received by us. Please request the Bankteller (in the case of a cash deposit) to clearly indicate your reference number on the statement.

(3) DEBIT ORDER: A debitorder form can be obtained from the organisation's Head Office. This is our prefered method of payment.

(4) RECURRING INTERNET PAYMENT: This option will be of great value to us and yourself, as late payments are charged interest according with the allowance made by the Credit Act.

Special Conditions:   Signed at:
On this day:   In the year:
Of the month:   Client / Patient:
Payer and Responsible Person as Relative:   Payer and/or Responsible Person as Trustee,
Curator or Official:

Please download the Checklist for Admission and bring it along to your appointment

 

Community Mental Health & Psychiatry


Checklist for Admission (LW: Ook van toepassing op staatspasiënte waar van toepassing)

Die volgende items/ dokumentasie moet 'n nuwe toelating vergesel. Hierdie lys moet by opname aan die fasiliteitsbestuurder aan diens oorhandig word en nagegaan word tot tevredenheid van die bestuurder alvorens die opname mag plaasvind.

By Aansoek: (Wat saam met u aansoek ingehandig moet word by Hoofkantoor alvorens u aansoek oorweeg kan word). Die Betrokke Direkteur of Fasiliteitsbestuurder moet die relevante blokkie hieronder duidelik parafeer. Slegs wanneer alle blokkies geparafeer is deur die relevante gemagtigde Direkteur of Fasiliteitsbestuurder, mag die opname gedoen word.

1. Volledig ingevulde aansoekvorm wat insluit:
1.1. Geen oop / oningevulde spasies op aansoekvorm.
1.2. Alle dokumentasie waarna in die aansoekvorm verwys word, (bewys van aansoek vir staatspensioen, bankstate, afskrifte van testamente van aansoeker & ouers van aansoekers, trustaktes, huweliksertifikate, egskeidingsbeville, beëdigde verklarings ens.) aangeheg.
1.3. Volledig ingevulde mediese vraelys hierby aangeheg.
1.4. Afskrif van identiteitsdokument.
1.5. Afskif van 'All Pay' kaart
1.6. Volledig getekende debietorder vir bybetaling wat aan u voorsien word (aangeheg by aansoekvorm).
1.7. Twee ID foto's van inwoner.
1.8. Ander:

By Opname: (Die Fasiliteitsbestuurder aan diens moet toesien dat die volgende aan hom / haar oorhandig word op dag van opname)

2. Geen opname mag plaasvind indien die volgende nie in plek is nie.
2.1. Opname brief uitgereik deur Hoofkantoor. Hierdie brief word slegs deur Hoofkantoor uitgereik wanneer alle dokumentasie, opnamefooi en eerste maand se fooie betaal is.
2.2. Medikasie voorskrif of afskrif daarvan.
2.3. Minstens een maand se voorraad medikasie.
2.4. Eie bed met matras (verkieslik nuut maar definitief in 'n goeie toestand).
2.5. Eie toesluitbare klerekas (verkieslik nuut maar definitief in 'n goeie toestand).
2.6. Eie bedkassie (verkieslik nuut maar definitief in 'n goeie toestand).
2.7. Vyf (5) stelle klere (verkieslik nuut maar definitief in 'n goeie toestand).
2.8. Vyf (5) volledige stelle onderklere (definitief nuut).
2.9. Vyf (5) pare sokkies (verkieslik nuut maar definitief in 'n goeie toestand).
2.10. Minstens twee (2) pare skoene en verkieslik plakkies en pantoffels daarby (verkieslik nuut maar definitief in 'n goeie toestand).
2.11. Twee (2) warm truie of baadjies (verkieslik nuut maar definitief in 'n goeie toestand).
2.12. Tien (10) hangers.
2.13. Twee (2) bad handdoeke (nuut).
2.14. Twee (2) waslappe (nuut).
2.15. Een (1) Duvet 'inner'(nuut).
2.16. Twee (2) duvetoortrekseis (nuut).
2.17. Twee (2) kussings (nuut).
2.18. Vier (4) kussingslope (nuut).
2.19. Twee (2) paslakens (nuut).
2.20. Twee (2) lakens (nuut).
2.21. Een (1) warm kombers (nuut).
2.22. Een (1) plastiek matras oortreksel (nuut: slegs indien van toepassing).
2.23. Toiletware: Tandeborsel, tandepaste, skeermes & lemmetjies, seep shampoo, reukweerder, kam en borsel, weggooibare sneesdoekies, een (1) stoflap ens.
2.24. Genoegsame koffie, tee en suikervoorrade. (opsioneel).
2.25. Alle eiendom en klerasie moet duidelik en sigbaar gemerk wees.
2.26. Ander:

Opname gedoen deur:

Datum:

 

Completed - Please awnser the Verification question and then press finish

This is a Verification Question


Please print out below, fill it out and return
Application form.pdf (1026 KB)