Client Registration Form
Contact Information
Name
*
First Name
Last Name
Date of birth
*
-
Month
-
Day
Year
Date
Gender
*
Please Select
Male
Female
Non-binary
A gender not listed here
Prefer not to say
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Contact Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Emergency Contact Details
Emergency Contact 1:
*
First Name
Phone Number
Emergency Contact 2:
*
First Name
Phone Number
Medical/Disability Information
What best describes your disability?
*
Spinal cord injury
Spina Bifida
Vision Impairment
Cerebral Palsy
Other neurological impairment
Other
What level is your SCI?
*
Do any of the following relate to you?
*
Rows
Yes
No
Low blood pressure
Autonomic Dysreflexia
Current pressure injuries
Current open wounds, cuts, abrasions or stitches
Osteoperosis
Admission to hospital in last 3 months
Fracture/s in last 12 months
Head/brain injury or memory loss
Recent surgery
Respiratory complications
Moderate to severe spasm/spasticity
Diabetes
History of heart disease or heart disorder
Pregnant or actively trying to fall pregnant
Been advised by your doctor not to exercise
If yes to any, please describe below
*
Do you have any other health condition or disabilities?
*
Yes
No
If yes, please describe below:
*
Funding Information
How are you funded?
*
NDIS
icare
Other insurance scheme
Other
How is your NDIS managed?
*
Self Managed
Plan Managed
*
Support Requirements
What adaptive recreation are you most interested in?
*
Tell us about the support you require?
*
Can you please tell us about your transfer skills?
*
New to transferring and require full support.
Can transfer but prefer to be spotted/surpervised.
2 person lift.
Hoist transfer
Confident and can transfer to and from chair on level surface.
Strong transfer from different heights.
Standing transfer
Other
If other, please describe?
Our equipment has weight restrictions and adjustments please choose the closet range so we can set it up accordingly?
Under 50kg
51-60kg
61-70kg
71-80kg
81-90kg
91kg-100kg
100kg+
Frequency of support required?
*
Weekly
Fortnightly
Monthly
Other
If other, please describe?
How did you hear about us?
*
Instagram.
Facebook.
Word of mouth.
Referred by allied health professional.
Other
If other please tell us how?
Submit
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