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1800 422 737 (& press 1)
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Which best describes you?
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I am a carer
I am referring a carer from an organisation
I am referring a carer that I know personally
How did you hear about us?
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Date
*
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Referrers details
Referring organisation
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First name
*
Last name
*
Phone
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Email
Do you have consent to share this information with us?
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Comments
Carer Details
Title
Mr.
Mrs.
Ms.
Dr.
Prof.
First Name
*
Last Name
*
Address
*
Street Address
City
State
Post Code
Phone
Mobile
Email
Preferred Communication Method
Phone
Email
Mail
SMS
Best time to contact
Country of Birth
Date of Birth
Gender
Male
Female
Non-Binary
[I/Them] use a different term
Decline to Answer
Other
Ethnicity
Australian
Acehnese
Afghan
African American
Afrikaner
Akan
Albanian
Algerian
American
Amhara
Anglo-Burmese
Anglo-Indian
Angolan
Arab, n.e.c.
Argentinian
Armenian
Assyrian/Chaldean
Australian Aboriginal
Australian South Sea Islander
Austrian
Azeri
Balinese
Barbadian
Basque
Batswana
Belarusan
Belgian
Bengali
Berber
Bermudan
Bolivian
Bosnian
Brazilian
British, n.e.c.
Bruneian
Bulgarian
Burgher
Burmese
Canadian
Caribbean Islander, n.e.c.
Catalan
Central American, n.e.c.
Central and West African, n.e.c.
Central Asian, n.e.c.
Channel Islander
Chilean
Chinese
Chinese Asian, n.e.c.
Colombian
Cook Islander
Coptic
Costa Rican
Croatian
Cuban
Cypriot
Czech
Danish
Dinka
Dutch
Eastern European, n.e.c.
Ecuadorian
Egyptian
English
Eritrean
Estonian
Ethiopian
Fijian
Filipino
Finnish
Flemish
French
French Canadian
Frisian
Georgian
German
Ghanaian
Gibraltarian
Greek
Guatemalan
Gujarati
Guyanese
Hawaiian
Hazara
Hispanic (North American)
Hmong
Hungarian
Hutu
Icelandic
I-Kiribati
Indian
Indonesian
Iranian
Iraqi
Irish
Italian
Ivorean
Jamaican
Japanese
Javanese
Jewish
Jordanian
Kadazan
Karen
Kazakh
Kenyan
Khmer
Korean
Kurdish
Kuwaiti
Lao
Latvian
Lebanese
Liberian
Libyan
Lithuanian
Luxembourg
Macedonian
Madurese
Mainland South-East Asian, n.e.c.
Malawian
Malay
Malayali
Maldivian
Maltese
Manx
Maori
Maritime South-East Asian, n.e.c.
Masai
Mauritian
Mayan
Melanesian and Papuan, n.e.c.
Mexican
Micronesian, n.e.c.
Moldovan
Mon
Mongolian
Montenegrin
Moroccan
Mozambican
Native North American Indian
Nauruan
Nepalese
New Caledonian
New Zealander
Nicaraguan
Nigerian
Niuean
Ni-Vanuatu
North American, n.e.c.
Northern European, n.e.c.
Norwegian
Not stated/Inadequately described
Nuer
Oromo
Other North African and Middle Eastern, n.e.c.
Other North-East Asian, n.e.c.
Pakistani
Palestinian
Papua New Guinean
Paraguayan
Pathan
Peruvian
Polish
Polynesian, n.e.c.
Portuguese
Puerto Rican
Punjabi
Roma/Gypsy
Romanian
Russian
Salvadoran
Samoan
Saudi Arabian
Scottish
Serbian
Seychellois
Sierra Leonean
Sikh
Singaporean
Sinhalese
Slovak
Slovene
Solomon Islander
Somali
Sorb/Wend
South African
South American, n.e.c.
South Eastern European, n.e.c.
Southern and East African, n.e.c.
Southern Asian, n.e.c.
Southern European, n.e.c.
Spanish
Sudanese
Sundanese
Swedish
Swiss
Syrian
Tahitian
Taiwanese
Tajik
Tamil
Tanzanian
Tatar
Temoq
Thai
Tibetan
Tigrayan
Tigre
Timorese
Tokelauan
Tongan
Torres Strait Islander
Trinidadian (Tobagonian)
Tunisian
Turkish
Turkmen
Tuvaluan
Ugandan
Uighur
Ukrainian
Uruguayan
Uzbek
Venezuelan
Vietnamese
Vlach
Welsh
Western European, n.e.c.
Yemeni
Yoruba
Zambian
Zimbabwean
Zulu
Main Language
Pension Status
Aged Pension
Carer Allowance
Carer Payment (Pension)
Disability Support Pension
No Government Pension or Benefit
Not States / Inadequately Described
Other Government Pension or Benefit
Unemployment Related Pension or Benefits
Veterans Affairs Pension
Employment Status
Paid work full-time
Paid work part-time
Unpaid work (includes volunteering)
Not working and not looking for work
Unemployed (not working but looking for work)
Studying full-time
Studying part-time
Caring
Parenting
Do you have any disabilities or medical conditions?
Does the carer have any disabilities or medical conditions?
Primary Carer
Yes
No
Caring role commenced
DD slash MM slash YYYY
How many people do you care for?
What is the disability or condition of the person you care for?
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