CCEAP Application
Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Who is this for?
Adult
Child 11 or older
Both
What service are you interested in?
Individual EAP
Horse Wisdom Group
Both
Which timeslots are you available? (Tick all available times)
Monday mornings (10-12am)
Monday afternoons(12-2.30pm)
Tuesday mornings (10-12am)
Tuesday afternoons(12-2.30pm)
Wednesday mornings (10-12am)
Wednesday afternoons(12-2.30pm)
Thursday mornings (10-12am)
Thursday afternoons(12-2.30pm)
Weekends
How will you be paying for sessions?
NDIS: Plan managed
NDIS: Self managed
Privately funded: Paying myself
Other
Anything else you would like us to know?
Submit
Should be Empty: