Request for Assistance Form

Name*

First NameLast Name

Email*

example@example.com

Phone*

Best contact number

What are your main concerns and how can we help you?*

Do you have any reports to help support your request for assistance?*

YesNo

Do you have any quotes for items or services that you are requesting?*

YesNo

If requesting permanent modifications or fixtures, can you please confirm your current living situation*

Living in Own HomePrivate RentCommunity HousingBoarding with Someone Else

If you are living in a rental property or living with someone else, do you have permission to make modifications to the property?*

YesNoNot Applicable

Are you an NDIS recipient or do you receive My Aged Care funding?*

YesNo

If Yes, please tick which is applicable to you*

NDISMy Aged CareNot Applicable

Please verify that you are human*

For full transparency, please note that all reasonable and necessary requests will be put forward for considerations. As a NON Profit branch, not all requests can be automatically granted, but we try our very best to provide as much help to were possible. We rely heavily on donations and fundraising efforts to be able to make this possible.