Register for a Freedom Wheels Assessment

To register for our Freedom Wheels program please enter your information into the form below. Alternatively, you can download a copy of the Freedom Wheels Application Form and fax or send it in to Solve Disability Solutions Central Office. 

This form requires you to provide us with details about riding experience and physical ability. This extra information enables us to immediately register and forward your request to our service team, and ensures the assessment bike is appropriately set up for your clinic.  If, at this stage, you simply wish to find out more about the Freedom Wheels program, you may prefer to submit a General Enquiry from our website or call Solve on 1300 663 243.

Note: If you are an agent registering for Freedom Wheels on behalf of the client, please make sure the client and/or their carers are informed. They will be receiving information from us in the mail, and it can be confusing if they are not aware of the request.

  1. Client Details

  2. Name*
    Please enter clients name
  3. Address*
    Please enter clients address
  4. Suburb*
    Please enter clients suburb
  5. Postcode*
    Please enter clients postcode
  6. Phone Number
    Please enter clients phone number
  7. Mobile Phone Number
    Invalid Input
  8. Email Address
    Please enter email address
  9. Date of Birth*
    Please enter date of birth
  10. Diagnosis*
    Please enter diagnosis
  11. Client Background

  12. 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.
  13. Are you of Aboriginal or Torres Strait Islander origin?
    Invalid Input
  14. How would you describe your ethnic or cultural heritage (ie. the ancestry that you identify with)?

    Please make a selection
  15. Please enter diagnosis
  16. Are there any cultural or religious requirements that Solve needs to be aware of?

    Please make a selection
  17. Please enter details of your request
  18. Will you require the assistance of a translator?

    Please make a selection
  19. Please enter diagnosis
  20. Next of Kin Details

  21. Next of Kin
    Invalid Input
  22. Relationship to Client
    Invalid Input
  23. Phone Number
    Please enter clients phone number
  24. Email Address
    Please enter email address
  25. Agent Details

  26. Name
    Please enter clients name
  27. Address
    Please enter clients address
  28. Phone Number
    Please enter clients phone number
  29. Email Address
    Please enter email address
  30. Occupation
    Please enter email address
  31. Project Contact

  32. Main contact for the project*
    Invalid Input
  33. Who is submitting this request?

  34. Requested By*
    Invalid Input
  35. Email Address*
    Please enter email address
    A confirmation email will be sent to this address if your request has been successfully submitted.
  36. If you have selected 'other', please provide the following additional contact details.
  37. Name
    Please enter the requester name
  38. Phone Number
    Please enter the requesters phone number
  39. How did you hear about us?*
    Invalid Input
  40. If 'other', please provide details.
  41. 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?*

    Please make a selection
  42. The following information is required to assist us to set up the bike ready for your clinic.
  43. Riding Experience

  44. Have you ever ridden a bike?*
    Invalid Input
  45. If yes, details of riding history/experience. What has been successful, what have been the limitations?
    Please enter details of your request
  46. Rider Specifics

  47. Weight (kg)*
    Invalid Input
  48. Height (cm)*
    Invalid Input
  49. 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.)
  50. Current Mobility

  51. Please tick appropriate box/es
  52. *





    Invalid Input
  53. Are postural supports required in wheelchair?






  54. Invalid Input
  55. Invalid Input
  56. Invalid Input
    If other, please provide details.
  57. Transfer Ability

  58. Please tick appropriate box.
  59. *



    Please make a selection
  60. Other relevant information

  61. Wears AFO's (Ankle Foot Orthosis)*
    Invalid Input
    If yes, please bring to the appointment.
  62. Recent Botox / Awaiting Botox*
    Invalid Input
  63. Invalid Input
    If yes, please provide details.
  64. Recent surgery / Awaiting surgery*
    Invalid Input
  65. Invalid Input
    If yes, please provide details.
  66. Please describe any significant restrictions to joint range of movement.
    Invalid Input
  67. Practicalities

  68. Has your therapist agreed that bike riding is a suitable activity for you?*
    Invalid Input
  69. Have you identified a safe place to ride your bike?*
    Invalid Input
  70. Invalid Input
    Example(s)
  71. Have you got someone to supervise your bike riding at all times?*
    Invalid Input
  72. 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.
  73. NDIS Clients

  74. NDIS Client Number
    Please enter email address
  75. Plan Start Date
  76. Plan End Date
  77. Is this service in your plan?

    Please make a selection
  78. How is this plan being managed?


    Please make a selection
  79. For Managed Plans we require the name of the Plan Manager
    Please enter diagnosis
  80. Upload your NDIS plan
    Invalid Input
    If you have an electronic copy of your current NDIS plan, you can upload your plan here.
  81. TAC Clients

  82. TAC Claim Number
    Please enter email address
  83. TAC Contact Name
    Please enter email address
  84. TAC Contact Phone
    Please enter email address
  85. TAC Contact Email
    Please enter email address
  86. Payment Details

  87. If this project is not being covered by NDIS or TAC, who will be paying for the project?
  88. Payment by client?

    Please make a selection
  89. If no, payment by
  90. Organisation
  91. Address
  92. Phone Number
  93. Email Address
  94. Privacy

  95. 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.
  96. *
    Please indicate your understanding of this privacy statement by ticking the box!