Client Details
Name*
Please enter clients name
Address*
Please enter clients address
Suburb*
Please enter clients suburb
Postcode*
Please enter clients postcode
Phone Number
Please enter clients phone number
Mobile Phone Number
Invalid Input
Email Address
Please enter email address
Date of Birth*
Please enter date of birth
Diagnosis*
Please enter diagnosis
Client Background
The following questions relate to your (or your client’s) cultural, linguistic and religious background. Solve collects this information to ensure we are able to respond effectively and in a culturally appropriate way to our clients’ needs. You may choose not to answer any of these questions. Any information you do provide will be kept confidential.
Are you of Aboriginal or Torres Strait Islander origin?
Yes No Invalid Input
How would you describe your ethnic or cultural heritage (ie. the ancestry that you identify with)?
Australian Other - please specify below (eg. Chinese, Sikh, Irish) Please make a selection
Please enter diagnosis
Are there any cultural or religious requirements that Solve needs to be aware of?
No Yes - please specify below. Please make a selection
Please enter details of your request
Will you require the assistance of a translator?
No Yes - please specify language below. Please make a selection
Please enter diagnosis
Next of Kin Details
Next of Kin
Invalid Input
Relationship to Client
Invalid Input
Phone Number
Please enter clients phone number
Email Address
Please enter email address
Agent Details
Name
Please enter clients name
Address
Please enter clients address
Phone Number
Please enter clients phone number
Email Address
Please enter email address
Occupation
Please enter email address
Project Contact
Main contact for the project*
Client Next of Kin Agent Requester Invalid Input
Who is submitting this request?
Requested By*
Client Next of Kin Agent Other Invalid Input
Email Address*
Please enter email address
A confirmation email will be sent to this address if your request has been successfully submitted.
If you have selected 'other', please provide the following additional contact details.
Name
Please enter the requester name
Phone Number
Please enter the requesters phone number
How did you hear about us?*
Used Solve previously Internet search E-newsletter Facebook Solve Seminar Customised bike day NDIS event Solve magazine/brochure Print Media Word of mouth - friends/family Word of mouth - health professional School Other Invalid Input
If 'other', please provide details.
IIs the client aware of this request and have they provided consent for the personal information provided on this form to be shared with Solve?*
Yes No Please make a selection
The following information is required to assist us to set up the bike ready for your clinic.
Riding Experience
Have you ever ridden a bike?*
Yes No Invalid Input
If yes, details of riding history/experience. What has been successful, what have been the limitations?
Please enter details of your request
Rider Specifics
Weight (kg)*
Invalid Input
Height (cm)*
Invalid Input
Inner leg length (cm)*
Invalid Input
(nb. minimum inner leg length for riding is 36cm measured from inner groin to heel of foot. For leg lengths shorter than this please contact Solve.)
Current Mobility
Please tick appropriate box/es
*
Are postural supports required in wheelchair?
Other mobility supports Invalid Input
Invalid Input
If other, please provide details.
Transfer Ability
Please tick appropriate box.
*
I can transfer on and off my chair / wheelchair without hands on assistance I can transfer on and off my chair / wheelchair with a small to moderate amount of assistance I require full assistance to transfer on and off my chair / wheelchair I can transfer myself on and off my wheelchair / chair if the environment is set up correctly for me Please make a selection
Other relevant information
Wears AFO's (Ankle Foot Orthosis)*
Yes No Invalid Input
If yes, please bring to the appointment.
Recent Botox / Awaiting Botox*
Yes No Invalid Input
Invalid Input
If yes, please provide details.
Recent surgery / Awaiting surgery*
Yes No Invalid Input
Invalid Input
If yes, please provide details.
Please describe any significant restrictions to joint range of movement.
Invalid Input
Practicalities
Has your therapist agreed that bike riding is a suitable activity for you?*
Yes No Invalid Input
Have you identified a safe place to ride your bike?*
Yes No Invalid Input
Invalid Input
Example(s)
Have you got someone to supervise your bike riding at all times?*
Yes No Invalid Input
Additional documentation
Invalid Input
If you have any additional documentation you would like to include with this request, such as a photo or file, you can upload it here.
NDIS Clients
NDIS Client Number
Please enter email address
Plan Start Date
Plan End Date
Is this service in your plan?
Yes No Please make a selection
How is this plan being managed?
NDIS Plan Managed Self Managed Please make a selection
For Managed Plans we require the name of the Plan Manager
Please enter diagnosis
Are you registered with SWEP (Statewide Equipment Provider) ?
No Yes - please provide SWEP registration number below. Please make a selection
Please enter diagnosis
Upload your NDIS plan
Invalid Input
If you have an electronic copy of your current NDIS plan, you can upload your plan here.
TAC Clients
TAC Claim Number
Please enter email address
TAC Contact Name
Please enter email address
TAC Contact Phone
Please enter email address
TAC Contact Email
Please enter email address
Payment Details
If this project is not being covered by NDIS or TAC, who will be paying for the project?
Payment by client?
Yes No Please make a selection
If no, payment by
Organisation
Address
Phone Number
Email Address
Privacy
The information collected by Solve Disability Solutions is for the purposes of processing your enquiry, request, registration, donation and/or for promotional purposes. Solve Disability Solutions discloses personal and sensitive information to the volunteer/employee involved in the provision of the service you have requested. If you are giving personal information about another person, e.g. next of kin, you should seek their permission beforehand and advise why you are disclosing their details to Solve Disability Solutions. (Read more in our
privacy policy ). Please indicate your understanding of this by ticking the box.
*
I understand Solve's privacy statement Please indicate your understanding of this privacy statement by ticking the box!
Submit Request
