Referral Form
Please select your state:
VIC
NSW
SA
WA
QLD
TAS
NT
ACT
I am interested in trialling:
Freedom
Wheels Cycle
Frame Runner
Please note, to successfully trial a Frame Runner you must be able to weight bear through at least one leg.
Who is the equipment for?
An Individual
An Organisation
Contact Information
Who will be the main point of contact for the person using the equipment
Client/Rider
Nominated Contact (eg. Next of Kin, House Manager, etc)
Client/Rider
Contact Details
Legal First Name
Legal Last Name
Email
Mobile
Date of Birth
Street Address
Suburb
Postcode
State
Please select...
NSW
VIC
QLD
WA
ACT
NT
TAS
SA
Nominated
Contact Details
Organisation Name
Role in the organisation
First Name
Last Name
Email
Mobile
Address same as client
Street Address
Suburb
Postcode
State
Please select...
NSW
VIC
WA
SA
ACT
QLD
NT
TAS
Relationship
Please select...
Parent
Next of Kin
Guardian
Carer
House Manager
Social Worker
Other Relative
Are you the emergency contact?
Yes
No
Emergency
Contact Details
First Name
Last Name
Email
Mobile
Relationship
Please select...
Parent
Next of Kin
Guardian
Carer
House Manager
Social Worker
Other Relative
Community Therapist Details(eg. Physio, OT, Exercise Physiologist)
First Name
Last Name
Work Email
Work Phone/Mobile
Organisation
Title
Upload any additional documentation you would like to include with this request, such as a photo or file.
Is there any other information you would like us to know (e.g. Behavioural concerns, types/components of bike or trike you would like to try)?
How did you hear about us?
Recommended by family, health professional, etc
Used the organisation before
Social Media
Internet Search
Blog or publication
Event
Other
Who is registering this request and to what email do you want the confirmation sent?
Client/Rider
Nominated Contact
Community Therapist
Other
First Name
Last Name
Confirmation Email address
I have read the Solve-TAD
Privacy Policy
.
Client Details
Diagnosis
Intellectual
Physical
Neurological
Vision
Acquired Brain Injury
Hearing
Speech
Psychiatric
Developmental Delay
Autism Spectrum Disorder
Other
Additional information about Diagnosis/Medical Conditions
Estimated Height
Edit this text
Cm
Ft
M
Estimated Weight
Edit this text
Kg
Lb
St
Do you require:
A hoist for transfers
A translator/interpreter is required
What language
Are you of Aboriginal or Torres Strait Islander origin?
Yes
No
What is your funding source?
NDIS
TAC
Privately Funded
My Aged Care
Other
Other funding information
Upload any additional documentation you would like to include with this request, such as a photo or file.
Is there any other information you would like us to know (e.g. Behavioural concerns, types/components of bike or trike you would like to try)?
How did you hear about us?
Recommended by family, health professional, etc
Used the organisation before
Social Media
Internet Search
Blog or publication
Event
Other
The client/rider is aware of this request and consents to have their details provided in this form shared with Solve-TAD
I have read the Solve-TAD
Privacy Policy
.