Unit 1, 23 Ashtan Place, Banyo, QLD 4014
1300 663 243
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Customer Information
Client First Name
First
Client Last Name
Last
Client DOB
Gender
Male
Female
Client Address
Suburb
Postcode
Client Phone
Client Email
Will you be using a funding package?
NDIS - Plan Managed
NDIS - Self Managed
NDIS - NDA Managed
MY AGED CARE: home care package
If NDIS, please add NDIS Number:
Contact Information
Parent/Carer Name (if applicable)
Parent/Carer First Name
First
Parent/Carer Last Name
Last
Relationship to client
Parent / Carer Phone
Parent / Carer Email
Referrer Information
Referrer First Name
First
Referrer Last Name
Last
Referrer Organisation
Referrer Job Title
Referrer Address
Suburb
Postcode
Referrer Phone
Referrer Email
Main Contact
Client
Parent/Carer
Referrer
Project Information
What is the challenge you are having?
What would you like TADQ to make or modify?
Has a commercially accessible option been investigated. If yes, what was the outcome?
If possible, please provide any specific measurements or design details, attach photos to form
Is the item to be located at another venue from clients address?
Yes
No
Please add alternative address
Health and Mobility
What is your medical condition and history?
Height cm
if applicable to the project
Weight km
if applicable to the project
Do you have any cognitive impairments that would affect this project?
Yes
No
Do you have any sensory impairments that would affect this project?
Yes
No
Is assistance needed for communication?
Yes
No
Do you have any other comments about your health that might effect this project?
Do you use any mobility aids? If yes, please describe
Are there any challenges we need to be aware of?
Please state your expected outcome/goal for this project?
Funding
For clients under 65 only
Country of birth
Payment
Indigenous Status
Torres Strait Islander Origin
Aboriginal Origin
Both
Neither
Living Arrangementts
Lives with family
Other
Please indicate how the item be paid for?
Self
NDIS
Betterstart
Insurance
Other
Other
How did you hear about our service?
Word of mouth
Social media
Event
Previous client
Website
Other
Other
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