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1300 663 243
Request a Service
Donate
Menu
Services
Unique Solutions
Adaptable Solutions
Freedom Wheels
Inclusive Community Sports Days
Funding Options
Enquire
About Us
Our Mission
Our Impact
Our History
Careers
Get Involved
Donate Now
Donate Monthly
Volunteer
Leave a Gift in Your Will
Get Involved with an Event
Workplace Giving
Corporate Partnerships
Stories
Our Shop
News
Request a Service
Donate
Request a Service
Home
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Request a Service
Select your product
Equipment Solution
Freedom Wheels
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Select your state
VIC
NSW
SA
WA
QLD
TAS
NT
ACT
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Select your state
NSW
VIC
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I am interested in trialling
Freedom Wheels Cycle
Frame Runner
Please note, to successfully trial a Frame Runner you must be able to weight bear through at least one leg.
Who is the equipment for?
An Individual
An Organisation
Who will be the main point of contact for the person using the equipment
Client/Rider
Nominated Contact (eg. Next of Kin, House Manager, etc)
Client/Rider
Contact Details
Legal First Name
Legal Last Name
Email
Mobile
Date of Birth
Address Details
Street Address
Suburb
Postcode
State
Please select...
NSW
VIC
QLD
SA
WA
ACT
NT
TAS
Nominated
Contact Details
Organisation Name
Role in the organisation
First Name
Last Name
Email
Mobile
Address Details
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Address same as client
Street Address
Suburb
Postcode
State
Please select...
NSW
VIC
QLD
SA
WA
ACT
NT
TAS
Relationship
Please select...
Parent
Next of Kin
Guardian
Carer
House Manager
Social Worker
Other Relative
Are you the emergency contact?
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Yes
No
Emergency
Contact Details
First Name
Last Name
Email
Mobile
Relationship
Please select...
Parent
Next of Kin
Guardian
Carer
House Manager
Social Worker
Other Relative
Community Therapist Details(eg. Physio, OT, Exercise Physiologist)
First Name
Last Name
Work Email
Work Phone/Mobile
Organisation
Title
Who is registering this request?
What email do you want the confirmation sent?
Client/Rider
Nominated Contact
Community Therapist
Other
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First Name
Last Name
Confirmation Email address
Upload any additional documentation you would like to include with this request, such as a photo or file.
Any additional notes/comments for this request
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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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I have read the Freedom Solutions
Privacy Policy
.
What is your equipment-related issue?
What are your goals/what are you hoping to achieve?
What other equipment/solutions have you previously tried?
Do you have a solution in mind? (It's okay if you don't!)
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
I have read the Freedom Solutions
Privacy Policy
.
Client Details
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Diagnosis
Choose all that apply
Intellectual
Physical
Neurological
Vision
Acquired Brain Injury
Hearing
Speech
Psychiatric
Developmental Delay
Autism Spectrum Disorder
Other
Additional Information
About Diagnosis/Medical Conditions
Estimated Height
Please select...
Cm
Ft
M
Estimated Weight
Please select...
Kg
Lb
St
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A hoist for transfers is required
Yes
No
Client Cultural Details
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A translator/interpreter is required
Yes
No
What language
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Are you of Aboriginal or Torres Strait Islander origin?
Yes
No
Funding Details
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What is your funding source?
NDIS
TAC
Privately Funded
Other
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What is your funding source?
NDIS
TAC
Privately Funded
My Aged Care
Other
Other funding information
NDIS Information
NDIS Plan Number
How is this plan being managed?
Plan-Managed
Self-Managed
NDIA-Managed
Plan Start Date
Plan End Date
TAC Information
TAC Claim Number
TAC Contact Name
TAC Contact Phone
TAC Contact Email
Additional Information
Upload any additional documentation you would like to include with this request, such as a photo or file.
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Is there any other information you would like us to know (e.g. Behavioural concerns? Type of bike you would like to trial?).
Edit section title
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
Edit section title
Confirmation
The client/rider is aware of this request and consents to have their details provided in this form shared with Solve-TAD
I have read the Solve-TAD
Privacy Policy
.
