You Can Stay - Accommodation Support for Youth Cancer Patients

New Patient Referral Form

REFERRER DETAILS

Clinical Position: *

YOUTH CANCER PATIENT DETAILS

Patient Medicare Number: *

Medicare Card Reference Number *

Medicare Card Expiry Date *

Patient Email (required if key contact)

Patient Mobile (required if key contact)

Name of Escort: (if travelling alone input patient's details) *

Relationship to Patient *

Treatment Stage: *

New diagnosis
On Treatment
Relapse
Check up/tests

Treatment type: *

In-Patient
Out-Patient
Combination (in and out)

Is the patient enrolled in a clinical trial? *

Yes
No

Does the patient identify as being of Aboriginal and/or Torres Strait Islander origin? *

No
Yes - Aboriginal
Yes - Torres Strait Islander
Yes - Both Aboriginal and Torres Strait Islander

Treating hospital details

Treating Hospital name: *

Name of Patient's treating Specialist: *

Home Hospital Name (essential if QLD Patient):

Check in date at Quest: *

Expected check out date (If known): *

Distance from place of residence to treating hospital (KM's): *

Supporting Information

Patient description & circumstances

- The young person's or family's background and current circumstance

- The financial impact of the cancer experience & how this is beyond their current capacity to manage financially

Primary contact for Quest in regards to completing the booking? *

Request for size of apartment *

Studio
1 Bedroom
2 Bedroom
Not sure

Approximate length of treatment requiring accommodation: *

a couple of weeks
at least one month
likely more than 3 months
likely more than 6 months
repeat bookings every month

Number of people staying in the apartment *

Please provided details of who is staying full time in the apartment *

Patient
Escort
Patient + Escort
Patient + Escort + Family

Some properties provide complimentary parking. If parking is essential and the patient/family are unable to cover their own parking costs, please indicate this and Sony Foundation will also cover the cost. Please note that if there is a need for long stay accommodation, we may request the patient/family stay at a Quest location with free parking.

Does the guest require parking?

ACCOMMODATION SUBSIDY

When a patient is accepted on to the You Can Stay program, we ask that they, and their referring clinician assist with completing some forms for Sony Foundation to secure a rebate from the government to offset some of the costs incurred to provide the accommodation. Please indicate below their eligibility, and note the extra detail required for VIC, QLD and TAS.

Is the Patient eligible for patient travel and accommodation subsidy in their state? *

Yes, has applied/confirmed
Yes, has not applied / confirmed yet
No, not eligible
Not sure

VIC Patient: Does the patient live in a Dept of Health designated rural health region?

Yes
No
Not sure

What is their local referring hospital?

TAS Patient: Is the patient registered with their local TAS PTAS office?

If a Patient is NOT ELIGIBLE:

A reason must be submitted at the time of referral for Sony Foundation to submit the stay under special considerations for funding approval. Considerations to include: family under financial difficulty, on a clinical trial, only just fall under the distance to qualify, etc.

If the patient is approved, the stay will only be granted for a maximum of 6 weeks, unless exceptional circumstances. During this time alternative accommodation needs to be arranged.

Please provide additional information and any exceptional circumstances as to why the patient needs support

Data Collection *

Yes - I, the referrer, consent to Sony Foundation collecting sensitive information about me. I also represent and warrant that the patient has consented to Sony Foundation collecting sensitive information about them.
No

Thank you for completing the referral form.

Please make sure to click the SUBMIT button below.

If your form has been successfully submitted online, you will receive a confirmation email.

If you do not receive a confirmation email, please try again or email the patient details to info@sonyfoundation.org.au

Sony Foundation will advise if the patient meets eligibility criteria.

Quest will then contact the primary contact to coordinate the accommodation in the next 24 - 48 hrs.

If you have any questions, please contact; info@sonyfoundation.org.au

Sony Foundation Australia is a charity proudly registered with the ACNC

You Can Stay - Accommodation Support for Youth Cancer Patients

New Patient Referral Form

REFERRER DETAILS

YOUTH CANCER PATIENT DETAILS

Address Details:

Treating hospital details

Supporting Information

DETAILS FOR QUEST

ACCOMMODATION SUBSIDY

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