Request for Information

Thank you for reaching out to us.
One of our intake team members will give you a call as soon as possible to discuss your requirements.

The answers below are so we can make sure the right person contacts you back. It is not a requirement, so please only share the information that you are comfortable with.

If your request is urgent, you can contact us on 07 3359 9004 or 045 678 2092 after hours.

Your Name*

First NameLast Name

Your Phone Number*

Area CodePhone Number

Your Email*

example@example.com

Funding Model*

Participant's Name*

First NameLast Name

Date of Birth*

Date

Disability*

Which Services are you interested in?

Are you interested in Jack's Butterflies managing your existing staff?

	YES/NO	Regular/One-Off	Please provide as much information that you are comfortable with sharing
BYO Staff ~ Managing existing staff
BYO Staff ~ Team Leader Only

Are you interested in the following - IN-HOME SUPPORT?

	YES/NO	Regular/One-Off	Please provide as much information that you are comfortable with sharing
DAILY LIVING ~ Domestic Assistance
DAILY LIVING ~ Standard Support Worker
DAILY LIVING - High Intensity Support

Are you interested in the following - COMMUNITY NURSES?

	YES/NO	Regular/One-Off	Please provide as much information that you are comfortable with sharing
NURSING ~ Home Care Support
NURSING ~ Community Access
NURSING ~ Nurse Visits, Assessments & Treatments
NURSING ~ Developing Treatment/Care Plans
NURSING ~ Case Management
NURSING ~ On-Call Assistance Program

Are you interested in the following - COMMUNITY ACCESS?

	YES/NO	Regular/One-Off	Please provide as much information that you are comfortable with sharing
COMMUNITY PARTICIPATION ~ Travel & Transport Arrangements
COMMUNITY PARTICIPATION ~ Access the Community with Supports

Are you interested in the following - SUPPORT COORDINATION?

	YES/NO	Regular/One-Off	Please provide as much information that you are comfortable with sharing
SUPPORT COORDINATION ~ Level 2
SUPPORT COORDINATION ~ Level 3
SUPPORT COORDINATION ~ Level 2 & Level 3
SUPPORT COORDINATION ~ Support Worker Team Leader

Is there a time and/or day that is better to hear from us?*

eg. anytime until 8pm.

How did you hear about us?*

If referred by a staff member - please tell us their name

We aim to respond to your request within 48 hours.

Thank you.

Please verify that you are human*

Request for Information

Tell us a bit about the person needing support