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Expressions of Interest & Enquiries
Who is this enquiry for?
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Myself
Family member or friend
Client of my service
Other
How long would you like to have a getaway for?
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Day trip (1 day, 0 nights)
Short trip (Less than 3 days)
Extended stay (More than 3 nights)
Other
What type of support is required?
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None - house only
House only + transport
Day support only (e.g., no sleepover staff required)
Day + Night support (e.g., sleepover or active night staff required)
Other
How many people would like to have a getaway?
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1
2
3
4
Person 1
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First Name
Last Name
Gender
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NDIS #
*
Person 2
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First Name
Last Name
Gender
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NDIS #
*
Person 3
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First Name
Last Name
Gender
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NDIS #
*
Person 4
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First Name
Last Name
Gender
*
NDIS #
*
Additional information & details
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Please provide more information that we need to know when providing support. For example, medical alerts, mobility needs, allergies, what your current situation is like, why you would like respite, etc.
I understand that this is an Expression of Interest only, and I may need to fill in additional forms or provide more information to secure services.
Who is the best person to contact about this enquiry?
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First Name & Last Name; Role (where applicable)
How would they like to be contacted?
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If you prefer phone contact, provide your phone number. If you prefer email contact, provide your email address
Your Signature
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