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Home
About
Services
Group Homes
Services at the Home
The Welcome Club
Applications
Application Form
Application Process Explained
FAQs
Comcare FAQs
Application FAQs
Legal FAQs
Contact
Applications
Download Application Form
Download Medical Report
Complete the form to apply for residency.
Complete the online form to apply for residency. Alternatively download the form and email the completed form back to applications@comcare.co.za
Please enable JavaScript in your browser to complete this form.
Please enable JavaScript in your browser to complete this form.
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Step
1
of 7
Applicant Information
Name & Surname:
*
First
Last
Email
*
Contact Telephone No
Current Address:
Address Line 1
Address Line 2
City
State / Province / Region
Who do you currently reside with?
ID Number:
Date of Birth:
Age:
Relationship Status
Single
In a relationship
Committed Partnership
Married
Separated
Divorced
Widowed
Do you have any children?
Yes
No
How many Children do you have?
Religion:
Next
Mental Health Information
Applicant Psychiatric Diagnosis:
When was the diagnosis first made?
Has the diagnosis changed?
Latest admission?
Total number of admissions:
Please list the dates of admission and places admitted to for psychiatric treatment.
Current treatment facility:
File Number:
Current Psychiatrist / Mental Health Nurse
Contact details of current Psychiatrist/ Mental Health Nurse
Email
Current psychiatric medication as prescribed by the above psychiatrist/mental health nurse.
Has there been any changes to your medication recently?
If yes, please indicate what medications/dosages have changed.
Next
Physical Health
Please indicate what health concerns you are currently receiving treatment for:
Epilepsy
Diabetes
Asthma
Heart Condition
Rheumatic Fever
High/Low Blood Pressure
Allergies
Please specify if you are struggling with any other physical health conditions.
Please list the medication you are using to manage the above health concerns.
Do you have any allergies (food/medication/pets, etc)?
Have you had a Covid-19 Vaccination?
Yes
No
If yes, please send copy of vaccination certificate
Next
Alcohol and Drug Use
Do you have a history of substance abuse?
Yes
No
If yes, What substances did you abuse?
When was the last time you used?
Do you currently consume alcohol?
Yes
No
Do you currently smoke?
Yes
No
What do you smoke
Cigarettes
Marijuana
Other
Have you ever received treatment for alcohol or drug use?
Yes
No
Next
Daily Activities and Routine
Are you currently employed?
Yes
No
Employer
Job Description/Title
Have you ever attended rehabilitation, OT, or support groups?
Yes
No
If yes, please specify what groups you’ve attended.
currently Employer COMCARE?
What do you currently do during the day?
How many of the following are you able to do for yourself?
Administer own medication
Administer own money
Take care of personal hygiene
Cook food
Clean room
Wash & Iron clothes
Tidy the home
What means of transport do you use?
Are you a SASSA grant recipient?
Yes
No
Income per month:
Total expenses per month:
Why do you require accommodation at COMCARE?
Next
Family & Next of Kin
Please provide the information of three to four family members or close friends.
Name:
Relation:
Address
Address Line 1
City
State / Province / Region
Phone
Email
Name:
Relation:
Address
Address Line 1
City
State / Province / Region
Phone
Email
Name:
Relation:
Address
Address Line 1
City
State / Province / Region
Phone
Email
Income Source
Relation:
Name:
Phone
Address
Address Line 1
City
State / Province / Region
Email
Next
Attach Documentation
Date of Application:
*
Please attach any relevant reports: (Mental Health Professional, Psychologist, Social Worker, Occupational Therapists)
Click or drag files to this area to upload.
You can upload up to 10 files.
Submit
