Select your state
VIC
NSW
TAS
SA
WA
ACT
QLD
There is no Freedom Wheels provider for NT at the moment
Who is the equipment for?
Individual
Organisation
Nominated Contact Details
Organisation Name
Role in the Organisation
First Name
Last Name
Email
Mobile
How do you want us to contact you?
Email
Phone
Rider Details
Legal First Name
Legal Last Name
Date of Birth
Is the Client under 18 years of age?
Please select...
Yes, Client is under 18
No, Client is 18 or older
Street Address
Suburb
State
Postcode
Estimated Height (in cms)
Estimated Weight (in kgs)
Diagnosis Details
What are the rider's diagnosis? (Choose all that apply)
Intellectual
Physical
Neurological
Vision
Acquired Brain Injury
Hearing
Speech
Psychiatric
Developmental Delay
Autism Spectrum Disorder
Degenerative Condition
Other
Please specify
Please provide relevant details of diagnosis and conditions.
Due to the rider's behavioural issues and/or complexity, do you think you may require extra time for a trial? A trial usually takes one hour
Yes
No
Does the rider use a mobility aid?
Yes
No
Wheelchair
Walker
Walking Stick
Other
Please Specify
Does the Client require a Full Time Carer?
No, Client is Independent
Yes, Client requires a Full Time Carer
Client Mobile
Client Email
Legal Guardian Contact Details
First Name
Last Name
Email
Mobile
Relationship
Please select...
Family member (Parent)
Family member (Children)
Family member (Sibling)
Family member (Other)
Spouse/Partner
Guardian
How do you want us to contact you?
Email
Phone
Health Professional Details (Therapist/OT/Physio/Social Worker etc)
First Name
Last Name
Work Phone/Mobile
Work Email
Organisation
Title
Please select...
Social Worker
Physiotherapist
Occupational Therapist
Support Worker
Support Coordinator
Other Professional
Additional Information
Is there any Product you would like to try?
Upload any additional documentation you would like to include with this request, such as a photo or file.
Second photo or file (if any).
Third photo or file (if any).
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
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Please see our
Privacy Policy
.
Sign me up to receive news and offers from Freedom Solutions Australia. You can unsubscribe anytime. By submitting this form, you agree to Freedom Solutions Australia's Privacy Policy. Your privacy is important to us.
Please see our
Privacy Policy
.