Tell us a little about yourself
First Name
*
Last Name
*
Email
*
Phone number
*
Date of birth
*
-
Day
-
Month
Year
Date
Gender
*
Male
Female
Non-binary
I use a different term
Prefer not to disclose
Are you
*
Aboriginal
Torres Strait Islander
Both Aboriginal and Torres Strait Islander
Prefer not to say
Neither
Address
*
Street Address
Street Address Line 2
Suburb
State
Postcode
Tell us about the person you supported
What is the relationship you had with them?
*
Parent
Grandparent
Partner
Child
Sibling
Other Relative
Other
Their first name
*
Their last name
*
Date of death
*
-
Day
-
Month
Year
Date
Their gender
*
Male
Female
Non-binary
I use a different term
Prefer not to disclose
Is there anything you’d like us to know about what’s happening for you right now?
*
Consent and Permissions
Before we can support you, we need your consent to the following
I consent to Violet collecting and using my information so I can be contacted about support, in line with privacy requirements
*
Yes
No
I consent to relevant information being shared with other organisations or providers if needed to access support
*
Yes
No
I have permission to act on behalf of the person or people I care for (for example, to organise and set up services)
*
Yes
No
I’m happy to be contacted for follow-up surveys or evaluation to help improve services
*
Yes
No
Submit
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