Submit an Enquiry Enquirer Details *If you are the client skip ahead to the client details below Your First Name Your Last Name Your Mobile Number Your Email Address Your Post Code Relationship with Client –None–Associated ProviderAuntCase managerChildCousinCoworkerDaughterEmployeeEmployerFamilyFatherFriendGrandchildGranddaughterGrandfatherGrandmotherGrandsonGuardianHusbandMotherOther Family MemberParentPartnerSelfSonSupport CoordinatorUncleWife Client Details Client’s First Name Client’s Last Name Client’s Mobile Client’s Email Address Client’s Street Client’s Suburb * Client’s State i.e. VIC, NSW, WA * Client’s Postcode * Interpreter Required –None–Yes – for spoken language other than EnglishYes – for non-spoken communicationNo Reason for Enquiry NDISMedicareDVAPrivate client Primary health concern –None–UnknownBlindDeafDeafblind (dual disability)HearingLanguage DisorderMild Hearing LossModerate Hearing LossProfound Hearing LossSpeechVisionVision ImpairedVisionTHI – PedestrianAcquired Brain InjuryAdjustment DisorderADHDAutismAlcohol RelatedAlzheimers DiseaseAmputationAnkylosing SpondylitisAnoxia/HypoxiaAnxietyAphrasiaArthrogryposisAsperger SyndromeAtaxiaAutismBack InjuryBehavioural DisorderBi Polar affective DisorderCerebellar DegenerationCerebral LeukodystrophyCerebral PalsyCervical SpondylitisCharcot-Marie-Tooth DiseaseChildhood Apraxia of Speech (CAS)Conduct DisorderCongenital DeformityCVADementiaDepressionDevelopmental delay 0-5 yrs onlyDown SyndromeDysphasiaDyspraxiaDystoniaEating DisorderEpilepsyExpressive DisorderFamilial Spastic ParesisFriedreichs AtaxiaGlobal Developmental DelayGuillain Barre SyndromeHigher Functioning AutismHIV – related Brain InjuryHomocystinuriaHuntington’s DiseaseHyperopia (Long Sighted)Impulse Control DisorderInfectionIntellectualLanguage DisorderLiteracyMixed Receptive/Exp DisorderMotor Neurone DiseaseMultiple SclerosisMulti System AtrophyMuscular AtrophyMuscular DystrophyMyasthenia GravisMyopia (Short Sighted)NeurofibromatosisNeurologicalNeuropathyNystagmusObsessive Compulsive DisorderOppositional Defiance DisorderOsteo ArthritisOsteogenesis ImperfectaOther Brain InjuryOther NeurologicalOther PhysicalOther PsychiatricParkinsons DiseasePersonality DisorderPervasive Developmental DisorderPhysicalPolymyositisPost Polio SyndromePost Traumatic Stress DisorderPsychiatricReceptive Language DisorderRheumatoid ArthritisScheuermann’s DiseaseSchizophreniaScoliosisSemantic/Pragmatic DisorderSensory Processing Disorder/ Emotional RegulationSleep DisorderSpecific Learning Disability / ADDSpeechSpeech Delay / DisorderSpina BifidaSpinal Cord InjurySpinal Cord StenosisSpinocerebellar DegenerationStrabismusStutteringSubstance AbuseSyringomyeliaTHI – AssaultTHI – Home/Recreation AccidentTHI – MVATHI – OtherTHI – PedestrianTHI – Work AccidentTumour Secondary health concern –None–UnknownBlindDeafDeafblind (dual disability)HearingLanguage DisorderMild Hearing LossModerate Hearing LossProfound Hearing LossSpeechVisionVision ImpairedVisionTHI – PedestrianAcquired Brain InjuryAdjustment DisorderADHDAutismAlcohol RelatedAlzheimers DiseaseAmputationAnkylosing SpondylitisAnoxia/HypoxiaAnxietyAphrasiaArthrogryposisAsperger SyndromeAtaxiaAutismBack InjuryBehavioural DisorderBi Polar affective DisorderCerebellar DegenerationCerebral LeukodystrophyCerebral PalsyCervical SpondylitisCharcot-Marie-Tooth DiseaseChildhood Apraxia of Speech (CAS)Conduct DisorderCongenital DeformityCVADementiaDepressionDevelopmental delay 0-5 yrs onlyDown SyndromeDysphasiaDyspraxiaDystoniaEating DisorderEpilepsyExpressive DisorderFamilial Spastic ParesisFriedreichs AtaxiaGlobal Developmental DelayGuillain Barre SyndromeHigher Functioning AutismHIV – related Brain InjuryHomocystinuriaHuntington’s DiseaseHyperopia (Long Sighted)Impulse Control DisorderInfectionIntellectualLanguage DisorderLiteracyMixed Receptive/Exp DisorderMotor Neurone DiseaseMultiple SclerosisMulti System AtrophyMuscular AtrophyMuscular DystrophyMyasthenia GravisMyopia (Short Sighted)NeurofibromatosisNeurologicalNeuropathyNystagmusObsessive Compulsive DisorderOppositional Defiance DisorderOsteo ArthritisOsteogenesis ImperfectaOther Brain InjuryOther NeurologicalOther PhysicalOther PsychiatricParkinsons DiseasePersonality DisorderPervasive Developmental DisorderPhysicalPolymyositisPost Polio SyndromePost Traumatic Stress DisorderPsychiatricReceptive Language DisorderRheumatoid ArthritisScheuermann’s DiseaseSchizophreniaScoliosisSemantic/Pragmatic DisorderSensory Processing Disorder/ Emotional RegulationSleep DisorderSpecific Learning Disability / ADDSpeechSpeech Delay / DisorderSpina BifidaSpinal Cord InjurySpinal Cord StenosisSpinocerebellar DegenerationStrabismusStutteringSubstance AbuseSyringomyeliaTHI – AssaultTHI – Home/Recreation AccidentTHI – MVATHI – OtherTHI – PedestrianTHI – Work AccidentTumour Requested Service – Hold ctrl to select more than one Occupational TherapySpeech PathologyOther Other Comments How Did You Hear About Us? –None–Allied Health ProfessionalAnother clientClient Engagement OfficerConcentric Clinician (external referral)Concentric Clinician (internal referral)Education Setting- Early Childhood Teacher/SupportEducation Setting- Teacher/ Education SupportFamily/friendGeneral PractitionerGoogleGovernment Community Health ServiceGuardianLocal Area CoordinatorMedical SpecialistNewspaperOther NDIA OrganisationOther Rehabilitation CentreOther SpecialistPeak BodyPlan ManagerPrivate HospitalPrivate Outpatients ServicePublic HospitalPublic Outpatients ServiceRadioReceptionRecovery CoachRelationship ManagerSelf ReferralSelf Referral- ParentService Provider- Charity/Private/NFPSocial MediaWebsite