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ELIGIBILITY CRITERIA FOR MORAL HOME HELP SERVICE
The person must meet all of the following criteria:
1. Be a Singapore citizen or permanent resident.
2. Resides in a non-institutional household, and can live in mainstream community.
3. Be 60 years or age or older and home bound for valid reason. Respite service is
available to any adult who is wheel-chair bound or bed-ridden, or has to provide non-
stop care to someone critically ill.
4. Has no family member living in the same dwelling or in the vicinity who is able, and no
other adult living in the vicinity who is both able and willing, to prepared or provide
lunch and/or dinner, to provide essential personal hygiene care, or to do essential
housekeeping.
5. Agrees to be home when meals are delivered or other services are provided, and to
contact the programme’s staff when cannot be at home.
6. Agrees to pay a fee for services, according to the programme’s fee schedule.
7. Needs meal delivery service at least four times a week for a duration of at least one
week or personal hygiene/ housekeeping service at least once a week for a duration of
three weeks.
MORAL HOME HELP SERVICES FEE SCHEDULE
Monthly Meals Laundry Housekeeping Personal Escort Shopping*
Household Income 1/day 2/day per First Each Hygiene per per delivery
$ Wash hour extra hr per trip
visit
200 or less Free Free Free Free Free Free Free Free
PA, MFEC 0.50 1.00 1.00 2.50 2.50 2.50 5.00 Free
201 – 350
351 – 800 1.00 1.50 2.00 3.50 3.50 3.50 10.00 Free
801 – 1000 1.50 2.00 3.00 5.00 5.00 5.00 15.00 Free
1001 – 1500 2.00 3.00 4.00 7.50 7.50 7.50 20.00 1.00
1501 – 2000 2.50 4.00 5.00 10.00 10.00 10.00 30.00 2.00
2001 – 3000 3.00 5.00 6.00 12.50 10.00 12.50 40.00 3.50
Above 3000 3.50 6.00 7.00 15.00 10.00 15.00 60.00 5.00
* Items delivered will be charged at cost. However, if certain items are donated items then they
may be supplied free of charge to households with income not more than $1,000 per month.
(a) If there is a good reason, we are prepared to charge at a lower rate.
(b) The above charges are subject to change without notice. For clients being served they shall
be given notice of such changes, to give them adequate time to make alternative
arrangements, if any of the service is to be terminated.
(c) Where demands exceed our capacity, new eligible clients will be put on a waiting list. When
admitted to our programme, the referral party shall be informed.
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MORAL HOME HELP SERVICE
REFERRAL FORM
Home Help Services Required
Meals Delivery Laundry Service Services are not provided on Sundays
Housekeeping Personal Hygiene and Public Holidays.
Escort service for essential appointments Charges are determined by LHMSC.
I PERSONAL/SOCIAL PARTICULARS
Name of Applicant NRIC Date of Birth
Age ( )
Address Tel Sex
M F
Marital Status Race Language. Spoken
Single Married Divorced Widowed
CLIENT LIVES:
Alone With Spouse/Family With Caregiver With Roommates/Friend
With Name(s):_________________________________ Relationship_______________
EMERGENCY CONTACT: 1) Relationship_______________
HOME PHONE________________________WORK PHONE_________________________
EMERGENCY CONTACT: 2)_________________________ Relationship_______________
HOME PHONE________________________WORK PHONE_________________________
Name of Next of Kin Relationship Tel: Pager/Handphone
Age: Working: Yes No
Type of Accommodation PA No. Gross Monthly
Household Income ($)
Rental Purchased
1-room flat 3-room flat 5-room flat
2-room flat 4-room flat Exec/ Maisonette
Private Apartments/Condo Landed Property
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II DAILY PERSONAL/HEALTH CARE NEEDS
1. Functional Limitations
Amputation Bowel/Bladder (incontinence) Contractures Hearing Paralysis
Endurance Ambulation Speech Legally Blind Dyspnea with minimal exertion
2. Mental Status
Oriented Comatose Forgetful Depressed Disoriented Lethargic
Agitated Other ……………………………….
3. Personal Appearance
Neat/Clean Unkempt Dirty/Smelly
4. Bathing
Independent Needs help Receives help
5. Dressing
Independent Needs help Receives help
6. Eating
Independent Needs help Receives help
7. Daily Hygiene
Independent Needs help Receives help
8. Vision OK W/Out Glasses OK W/Glasses Limited Blind
9. Hearing Good OK W/Hearing Aid Limited Deaf
10. Communication Good Problematic
Specify Problem_____________________________________________________________
11. Uses Oxygen Insulin (oral) Insulin (inject) Diapers Other Needs
12. Bladder control
Good Partial Total Incontinence Manages independently Manages w/assistance
13. Bowel Control
Good Partial Total Incontinence Manages independently Manages w/assistance
14. Ambulation Independent Walker Wheelchair Bedridden
15. Cognition Good Not Oriented to: Person Place Time
16. Memory Loss None Mild Significant Severe
17 Emotional Affect Positive Openly Negative Depressed Agitated/Disturbed
18. Safety Measures: Allergies
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20. Medical History
ICD 10 Principal Diagnosis Date Medications: Dose/Frequency/Route
ICD 10 Surgical Procedure Date
ICD 10 Other Patient Date
Diagnosis
Reason (s) for referral:
III DAILY LIVING NEEDS
Paying Bill Independent Needs Help Receives Help
Answering Correspondence Independent Needs Help Receives Help
Housekeeping Independent Needs help Helped by Rel. Friend Homemaker
Grocery Shop Independent Needs help Helped by Rel. Friend Homemaker
Laundry Independent Needs help Helped by Rel. Friend
Transport Independent Needs help Helped by Rel. Friend Homemaker
Home Appearance Neat Cluttered Dirty Needs Repair (Health Hazard)
AGENCY PROVIDING OTHER SERVICES
Name_____________________________________________Tel _____________________
Address____________________________________________________________________
Contact Person______________________________________________________________
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SUGGESTED TREATMENT PLANS
Duration of Service Needed:__________________ Preferred start date: ________________
A) Nutritional Requirements:
Food Type: No restriction Vegetarian No beef Muslim (Please tick)
RECOMMENDED DIET: Normal/Soft diet and specific dates or frequency
Normal Soft Puree
Regular Diet
Low Sodium Diet
Diabetic Diets (specify Kcals)
Low fat/low cholesterol diet
Bland Diet
Others (please specify)
B) Medical Follow-Up
OPD Polyclinic : ________ .
Specify Clinic
SOC of referring hospital / Clinic ____________________________________________
Under management of ____________________________________________
Please state name of Medical Doctor
Source of Referral
Name Designation Agency
Address Tel Fax
Date of referral Recommended Fee Signature
___________________________________________________________________________
FOR OFFICIAL USE
Date Received Date Assessed Ref:
Accepted Rejected KIV
Payment Arrangement: from Client from others (Contact No. )
Service Effective Date Frequency Fees
Meals Delivery
Housekeeping
Personal Hygiene
Laundry Service
Escort service
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