To view our privacy policy, please click here: Free Living Australia - Privacy Policy Privacy Policy Approved * 1 Customer Information Select GenderMaleFemaleI prefer not to say 2 Support Details Select Support Type:Occupational TherapySpeech Pathology [group speech-pathology] SwallowingCommunicationVoiceOther [/group] Select Support TypeOngoing TherapyReportBothIf Other, Mention Below [group ongoing-therapy] Preferred Session FrequencyWeeklyFortnightlyMonthlyOther [group other] [/group] Preferred Session LocationHomeSchoolChildcare / KindergartenCommunityCentre-Based-ScoresbyTelehealthWorkplaceUnsureAny Other [group home] Preferred Day(s) for Services MondayTuesdayWednesdayThursdayFriday Preferred Time of Day AMPM Although we endeavour to offer you your preferred time and day, this will be subject to therapist availability. Funding TypeNDISPrivately FundedPrivate Health InsuranceHome Care Package [/group] [group centre-based-scoresby] Preferred Day(s) for Services MondayTuesdayWednesdayThursdayFriday Preferred Time of Day AMPM Although we endeavour to offer you your preferred time and day, this will be subject to therapist availability. Funding TypeNDISPrivately FundedPrivate Health InsuranceHome Care Package [/group] [group any-other] Preferred Day(s) for Services MondayTuesdayWednesdayThursdayFriday Preferred Time of Day AMPM Although we endeavour to offer you your preferred time and day, this will be subject to therapist availability. Funding TypeNDISPrivately FundedPrivate Health InsuranceHome Care Package [/group] [group ndis] Do you require a Plan Review Report at the end of your plan? YesNoUnknown How are the NDIS Funds managed?Self-ManagedPlan ManagedNDIA Managed [group self-managed] [/group] [group plan-managed] [/group] [group ndia-managed] [/group] [/group] [group privately-funded] [/group] [/group] [group report] Report Type (if known)Functional Capacity ReportPlan Review ReportChange of Circumstances ReportGeneral ReportAssistive Technology ReportOther Report [group other-report] [/group] Preferred Session FrequencyWeeklyFortnightlyMonthlyOther [group other] [/group] Preferred Session LocationHomeSchoolChildcare / KindergartenCommunityCentre-Based-ScoresbyTelehealthWorkplaceUnsureAny Other [group home] Preferred Day(s) for Services MondayTuesdayWednesdayThursdayFriday Preferred Time of Day AMPM Although we endeavour to offer you your preferred time and day, this will be subject to therapist availability. Funding TypeNDISPrivately FundedPrivate Health InsuranceHome Care Package [/group] [group centre-based-scoresby] Preferred Day(s) for Services MondayTuesdayWednesdayThursdayFriday Preferred Time of Day AMPM Although we endeavour to offer you your preferred time and day, this will be subject to therapist availability. Funding TypeNDISPrivately FundedPrivate Health InsuranceHome Care Package [/group] [group any-other] Preferred Day(s) for Services MondayTuesdayWednesdayThursdayFriday Preferred Time of Day AMPM Although we endeavour to offer you your preferred time and day, this will be subject to therapist availability. Funding TypeNDISPrivately FundedPrivate Health InsuranceHome Care Package [/group] [group ndis] Do you require a Plan Review Report at the end of your plan? YesNoUnknown How are the NDIS Funds managed?Self-ManagedPlan ManagedNDIA Managed [group self-managed] [/group] [group plan-managed] [/group] [group ndia-managed] [/group] [/group] [group privately-funded] [/group] [/group]Next 3 Other Information that would assist us in supporting the customer 4 Preferred Contact Person Details 5 Referrer Details How did you find us? * Free Living Australia WebsiteCurrent Free Living Australia CustomerEmail CommunicationWord of MouthSupport CoordinatorClickAbilitySocial MediaRe-ReferralDisability Service Finder WebsiteLACs/ECEIsOther Please upload any relevant documents (for example, your NDIS Plan, documentation from health professionals or other services, etc.). If you need to attach more than 5 documents, you can email these to [email protected] BackNext 6 Complete Form Are you ready to complete the form? Your responses cannot be changed after saving. Back
