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
TAS
Select your state
VIC
NSW
Who is the equipment for?
Individual
Organisation
Nominated Contact Details
Organisation Name
Role in the Organisation
First Name
Last Name
Email
Mobile
Funding Requirements
Please indicate if this bike or equipment will be:
Fully Self Funded
Yes
No
NDIS Funded
Yes
No
Please specify what third party will be funding the bike/equipment
Do you have a current NDIS plan
Yes
No
Please indicate your NDIS Plan Start Date
NDIS Plan End Date
NDIS Participant Number
Do you have bike funding in your current plan?
Yes
No
Not Sure
Does your plan include a goal of riding a bike?
Yes
No
Not Sure
Client/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
Please select...
VIC
NSW
TAS
Postcode
Estimated Height (in cms)
Estimated Weight (in kgs)
Diagnosis Details
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
Health Professional Details (Therapist/OT/Physio/Social Worker etc)
Your Health Professional /Therapist should attend your Freedom Wheels Bike Trial as they will be required to complete the NDIS Justification Report.
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
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 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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.
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
.