Select your product
Custom Assistive Technology Solution (Mobility Aids, Wheelchair modifications, Personal Care and Daily Living Aids, Sport & Recreation etc.)
Freedom Wheels (Bikes, Trikes, Electric Assist Cycles, and Frame Runners)
Select your state
VIC
NSW
SA
WA
QLD
TAS
NT
ACT
Select your state
NSW
VIC
Who is the equipment for?
Individual
Organisation
Nominated Contact Details
Organisation Name
Role in the Organisation
First Name
Last Name
Email
Mobile
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Client/Rider Contact Details
Is the Client under 18 years of age?
Please select...
Yes
No
Select "
Yes
" IF the client is
under 18
Select "
No
" IF the client is
above 18
Legal First Name
Legal Last Name
Email
Mobile
Date of Birth
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Address Details
Street Address
Suburb
State
Please select...
NSW
VIC
QLD
SA
WA
ACT
NT
TAS
Postcode
Client Contact Details
Is the Client under 18 years of age?
Please select...
Yes
No
Select "
Yes
" IF the client is
under 18
Select "
No
" IF the client is
above 18
Legal First Name
Legal Last Name
Email
Mobile
Date of Birth
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Privacy Policy
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Address Details
Street Address
Suburb
State
Please select...
NSW
VIC
QLD
SA
WA
ACT
NT
TAS
Postcode
Primary Contact Details
Is the Primary Contact same as Client?
Yes
No
First Name
Last Name
Email
Mobile
Relationship
Please select...
Parent
Next of Kin
Guardian
Carer
House Manager
Social Worker
Treating Therapist
Other
Organisation
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Community Therapist Details (OT/Physio etc)
First Name
Last Name
Work Phone/Mobile
Work Email
Organisation
Client Details
Diagnosis
Choose all that apply
Intellectual
Physical
Neurological
Vision
Acquired Brain Injury
Hearing
Speech
Psychiatric
Developmental Delay
Autism Spectrum Disorder
Other
Please Specify Other Conditions
Additional Information
About Diagnosis/Medical Conditions
Estimated Height
Height
Unit
Please select...
Cm
Ft
M
Height
Unit
Please select...
Cm
Ft
M
Estimated Weight
Weight
Unit
Please select...
Kg
Lb
St
Weight
Unit
Please select...
Kg
Lb
St
Equipment Related Questions
What is your equipment-related issue?
What are your goals/what you are hoping to achieve?
Have you tried any other equipment or Solutions?
Do you have a solution in mind?
Additional Information
Is there any other information you like to include? (e.g behavioural
concerns, type of bike you would like to trial)
Is there any other information you like to include? (e.g behavioural
concerns)
Is there any other information you like to include? (e.g behavioural
concerns)
Upload any additional documentation you would like to include with this request, such as a photo or file.
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
Preferred Mode of Communication
Please select your preferred mode of communication regarding this referral
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Email
Phone
Confirmation Email
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