Short-Term Accommodation

(STA) Booking Form

If you would like to check availability before filling in your form, please call us on 1800 329 104 and speak to one of our staff.

As you have requested to book a stay at Royal Rehab Private Petersham, we require you to fill out this form each time you would like to stay. This form gathers the information we need to make your stay as smooth as possible.

The pages you will go through during this form are:

Welcome Page
Personal Details
Mobility and Care Needs
Package Choice, Therapy and Funding
Agreement, Consent and Evaluation

Please note: This form is not a confirmation of a booking.

So we can tailor your stay to meet your individual needs, please complete the following form.

Once completed, our friendly staff will contact you to book your stay. We look forward to welcoming you.

Please contact us on 1800 329 104 if you need help with completing this form.

Welcome Page

Before submitting your booking please note eligibility criteria

My needs meet the primary purpose of Royal Rehab Private Petersham.
Royal Rehab Private Petersham is not equipped to support ventilator dependent participants, if you are ventilated, participants must come with their own carers.
If you use continuous Oxygen using a Concentrator, please contact us to discuss whether your support requirements can be met.
Royal Rehab Private Petersham cannot support you if you have significant behaviours of concerns or addictions that may affect the quiet enjoyment of other participants.
The staff at Royal Rehab Private Petersham are trained to support people with disabilities/neurological deficits and non-acute medical conditions. I understand that I might be required to bring my own trained support if my care requirements are complex and exceed the staff skill set.
Royal Rehab Private Petersham short term accommodation does not manage sudden onset of acute medical conditions. I understand that an ambulance will be called for me if I require medical attention and that I will be responsible for any costs incurred in transporting me and/or my equipment to and from hospital.

Royal Rehab Private does NOT supply the following items:

Medications
Bowel & Bladder continence supplies or night bags/bottles
Wound dressing supplies
Respiratory equipment
We do not provide enteral feeds equipment, you will be required to bring 3 days supply of your feeds at the beginning of your stay
We will do our best to provide equipment for your individual needs although in some cases, equipment may not be available which may result in either a delay in your booking or asking you to provide you own equipment from home

In booking a stay, I acknowledge that I meet the above criteria to stay at Royal Rehab Private Petersham *

No, I do not meet the above criteria

We cannot accept your booking if you do not meet the eligibilty criteria.

Return to Royal Rehab Private Petersham website

Personal Details

First name *

Last name *

Email *

Contact number *

Alternate contact number

Address *

Suburb *

State *

Post code *

Gender *

Date of birth *

Do you identify as Aboriginal or Torres Strait Islander? *

Preferred arrival date *

Preferred departure date *Minimum 3 nights booking required

Do you speak a language other than English at home? *

NoYes

Language spoken at home *

Interpreter required? *

NoYes

Do you have any cultural beliefs or values that you would like our staff to be aware of? *

NoYes

Please give details on cultural beliefs or values you would like us to be aware of *

Emergency Contact & GP Information

Emergency contact

Phone

Emergency contact’s relationship to you

GP Name

Phone

Practice Name

Mobility and Care Needs

What is your primary disability, neurological deficit or non-acute medical condition? *

Are you currently an inpatient at a hospital or a rehabilitation facility? *

NoYes

Name of hospital or facility *

Please note any other medical conditions *

Please list any allergies *

Is there anything about your mental health that you would like to tell us so we can better support you during your stay? *

NoYes

Please describe *

Do you have any health conditions or disabilities? *

NoYes

This may affect your therapy time allocation

Do you have any current infections such as VRE, MRSA etc.? *

NoYes

This may affect your therapy time allocation

Please specify your health conditions/disabilities *

Please specify your current infections *

What is your current weight and height? *This information is needed so we can provide the best equipment and care for your stay

Do you have an Advanced Care Directive *

NoYes

Please upload your Advanced Care Directive *

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Please upload a recent (last 3 months) medication list provided by your GP

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You are required to provide your own medication in a pharmacy dispensed webster pack. Please bring the correct amount for your entire stay. You may be required to submit an updated medication list prior to your arrival.

The medication list provided is current and correct *

Do you use a mobility aid? *

NoYes

What mobility aid do you use? *We recommend bringing in your own mobility aid for your stay.

Do you use a mobility aid to transfer? *

NoYes

What mobility aid do you use to transfer? *

Do you require assistance with personal care? *

NoYes

Will you be bringing in your own personal support worker to assist with personal care? *

No, I would like to book my personal care through Royal Rehab Private PetershamYes, I am bringing my own support workers and do not need to book any personal careYes, I would like to use a combination of my own support workers as well as booking personal care through Royal Rehab Private Petersham

*If you require assistance of 2 x nursing staff, we will contact you about an individualised cost per night.

Please upload Vaccination Evidence for your support worker/s

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Do you need assistance with showering? *

NoYes, SupervisionYes, 1 Person assistYes, 2 Person assist

Do you need assistance with toileting? *

NoYes, SupervisionYes, 1 Person assistYes, 2 Person assist

Please note that you will need to supply your own continence pads/stoma supplies/catheters if you require them

Do you need assistance with grooming? *

NoYes, SupervisionYes, 1 Person assistYes, 2 Person assist

Do you need assistance with dressing? *

NoYes, SupervisionYes, 1 Person assistYes, 2 Person assist

What feeds do you require? *Please note that you will need to bring all equipment in to assist you with your feeds along with 3 x days supply of feeds for your stay.

Please specify your dietary requirements *

Do you require thickened fluids? *

NoYes

What level of thickened fluids do you require? *

Mildly thick/ L2Moderately thick/ L3Extremely thick/ L4Nil by mouth

Do you have a communication impairment? *

NoYes

Please provide details of your communication impairment? *

Do you need assistance taking your medication? *

NoYes

What assistance do you require for your medication? *

Are there any challenging behaviours we need to be aware of? *

NoYes

Please describe the challenging behaviours/behaviours of concern. If available, please provide us a copy of your behaviour support plan *

Overnight is any care or assistance required between 9:30pm – 7:30am. If you require overnight care, please list your care needs and a member of our bookings team will be in contact to discuss. Overnight Support is available for emergencies.

Please list other equipment requirements with as much detail as possible to assist us to plan for your stay. *Some equipment requests may incur additional costs.

What sling size do you use for the hoist? *

SmallMediumLargeExtra Large

Package Choice, Therapy and Funding

When booking Short Term Accommodation at Royal Rehab Private Petersham, there are three packages available. All packages include up to 6 hours of personal care. *

Accommodation Package start from (STA and Assistance 1:1 01_058_0115_1_1) $832.00 per night Standard Therapy Package start from (STA and Assistance 1:1 with 1 session/day of 1:1 therapy 01_058_0115_1_1) $998.00 per nightIntensive Therapy package start from (STA and Assistance 1:1 with 2 sessions/day of 1:1 therapy 01_058_0115_1_1) $1165.00 per night

* If you require 2 people to assist you for therapy, the rehabilitation coordinator will contact you with an individualised cost per night

Please click here to read our Therapy Consent
I have read and understand my rights and responsibilities *

icare Participant number *

Please upload a copy of your icare approval or notice of assessment for your stay at Royal Rehab Private Petersham

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icare Coordinator First name *

icare Coordinator Last name

icare Coordinator Email *

icare Coordinator Phone

icare Case Manager's First name *

icare Case Manager's Last name

icare Case Manager's Email *

NDIS Participant Number *

NDIS Plan Start Date *

NDIS Plan End Date *

NDIS Support Coordinator First Name *

NDIS Support Coordinator Last Name

NDIS Support Coordinator Email *Notification will be sent to your Support Coordinator to advise of the booking request upon submission of this form.

NDIS Support Coordinator Phone

Plan Management Provider *

Plan Management Provider Phone

Plan Management Provider Email *Notification will be sent to your Plan Manager to advise of the booking request upon submission of this form.

Please upload your NDIS plan

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What goals are you looking to achieve by staying at Royal Rehab Private Petersham? *

Which therapies do you wish to participate in during your stay? *

PhysiotherapyOccupational therapyExercise Physiology (EP)Aquatic Physiotherapy

For the standard package please chose a maximum of 2 therapies. For the intensive package please chose a maximum of 3 therapies

What is your preferred time window for therapy? *

8:30am - 10:30am10:30am - 12:30pm1:00pm - 3:00pm

Other

Which funding category would you like to use for therapy? *

Capacity Building Core SupportsImproved Daily LivingImproved Health and Wellbeing (EP only)

Are you interested in accessing Speech Pathology during your stay? *

NoYes - $193.99/hr

Limited availability.

Will you be bringing an additional person with you for your stay? *

NoYes

Please note this will incur an additional self-funded fee of $100.00 per night

Will your additional person provide any assistance during your stay i.e assist with feeding, medication management, transport to social outings etc

NoYes

Please detail what the additional person will assist with:

Will you be bringing an assistance animal with you on your stay? *

NoYes

Please click here to read our Assistance Animals policy
I have read and agree to the policy of bringing an assistance animal? *

Please specify *

Do you have any additional comments or questions about your booking?

Agreement, Consent and Evaluation

Please click here to read Terms and Conditions
I have read, understood and agree to Royal Rehab Private Petersham Terms and Conditions. *

Please click here to read our Privacy, Dignity and Confidentiality policy
I have been provided with information regarding Royal Rehab Private Petersham Privacy, Dignity and Confidentiality Policy. *

I consent to other service providers/ agencies that provide me with supports/ services disclosing information to Royal Rehab Private Petersham to ensure appropriate management of my supports. *

I consent to Royal Rehab Private Petersham being in contact with other service providers/ agencies involved in my supports, to ensure appropriate management of my supports. *

I agree to let the provider know immediately if my funding approval/ NDIS plan is suspended or replaced by a new approval/ plan or if I stop receiving funding. *

I am aware of the fees associated with this service and I agree to let Royal Rehab Private Petersham secure funds or contact my plan manager *

I consent to a courtesy email being sent to my plan manager/ support coordinator notifying them of my STA booking request.

I acknowledge that I am personally responsible to pay all fees for services rendered. Should I exceed my funding allocation or engage services outside my approved funding, I will be personally responsible for payment of the account. *

I consent to being photographed for medication administration purposes *

Please click here to read our Multimedia Consent Policy
I have read the Multimedia Consent Policy and I consent to Royal Rehab Private Petersham using my image in various media.

I would like to be hear about up coming Royal Rehab Private Petersham activities, events and courses and I consent to joining the Royal Rehab group mailing list. You may receive information such as educational material, special events, fundrasing and promotional materials. In doing so I agree to the Privacy Collection Notice.

I give consent to be contacted or sent information about research opportunities that may be of interest to me.

Signature of Guest or guardian / representative *

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Date *

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