Who is the equipment for?
Individual
Organisation
Organisation Name
Role in the Organisation
First Name
Last Name
Email
Mobile
Equipment User Details
Legal First Name
Legal Last Name
Date of Birth
Gender
Street Address
Suburb
State
Please select...
VIC
NSW
Postcode
Estimated Height (in cms)
Estimated Weight (in kgs)
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.
Does the equipment user use a mobility aid?
Yes
No
Wheelchair
Walker
Walking Stick
Other
Please Specify
Is the user
under
18 years of age?
Please select...
Yes, User is under 18
No, User is 18 or older
Does the equipment user require a full-time carer?
No, the user is Independent.
Yes, the user 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
What is your planned funding source?
NDIS
My Aged Care
TAC
Private Purchase
Other
Please specify
Plan End Date
Plan Start Date
NDIS Participant Number
Health Professional Details
First Name
Last Name
Work Phone/Mobile
Work Email
Organisation
Title
Please select...
Social Worker
Support Worker
Physiotherapist
Occupational Therapist
Support Coordinator
Other Professional
Do you provide consent for Freedom Solutions Australia and your treating therapist to speak on your behalf?
Yes
No
What is your equipment-related issue?
Have you tried any other equipment or Solutions?
Do you have a solution in mind?
What are your goals/what you are hoping to achieve?
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).
Who is filling this form?
Client
Legal Guardian
Health Professional
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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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
.
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
.
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
.
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