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. Invalid Input
  12. Next of Kin Details

  13. Next of Kin
    Invalid Input
  14. Relationship to Client
    Invalid Input
  15. Phone Number
    Please enter clients phone number
  16. Email Address
    Please enter email address
  17. Agent Details

  18. Name
    Please enter clients name
  19. Address
    Please enter clients address
  20. Phone Number
    Please enter clients phone number
  21. Email Address
    Please enter email address
  22. Occupation
    Please enter email address
  23. Project Contact

  24. Main contact for the project*
    Invalid Input
  25. Who is submitting this request?

  26. Requested By*
    Invalid Input
  27. Email Address*
    Please enter email address
    A confirmation email will be sent to this address if your request has been successfully submitted.
  28. If you have selected 'other', please provide the following additional contact details.
  29. Name
    Please enter the requester name
  30. Phone Number
    Please enter the requesters phone number
  31. How did you hear about us?*
    Invalid Input
  32. If 'other', please provide details.
  33. Is the client aware of this request?*

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

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

  39. Weight (kg)*
    Invalid Input
  40. Height (cm)*
    Invalid Input
  41. 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.)
  42. Current Mobility

  43. Please tick appropriate box/es
  44. *





    Invalid Input
  45. Are postural supports required in wheelchair?






  46. Invalid Input
  47. Invalid Input
  48. Invalid Input
    If other, please provide details.
  49. Transfer Ability

  50. Please tick appropriate box.
  51. *



    Please make a selection
  52. Other relevant information

  53. Wears AFO's (Ankle Foot Orthosis)*
    Invalid Input
    If yes, please bring to the appointment.
  54. Recent Botox / Awaiting Botox*
    Invalid Input
  55. Invalid Input
    If yes, please provide details.
  56. Recent surgery / Awaiting surgery*
    Invalid Input
  57. Invalid Input
    If yes, please provide details.
  58. Please describe any significant restrictions to joint range of movement.
    Invalid Input
  59. Practicalities

  60. Has your therapist agreed that bike riding is a suitable activity for you?*
    Invalid Input
  61. Have you identified a safe place to ride your bike?*
    Invalid Input
  62. Invalid Input
    Example(s)
  63. Have you got someone to supervise your bike riding at all times?*
    Invalid Input
  64. 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.
  65. NDIS Clients

  66. NDIS Client Number
    Please enter email address
  67. Plan Start Date
  68. Plan End Date
  69. Is this service in your plan?

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


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

  74. TAC Claim Number
    Please enter email address
  75. TAC Contact Name
    Please enter email address
  76. TAC Contact Phone
    Please enter email address
  77. TAC Contact Email
    Please enter email address
  78. Payment Details

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

    Please make a selection
  81. If no, payment by
  82. Organisation
  83. Address
  84. Phone Number
  85. Email Address
  86. Privacy

  87. 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.
  88. *
    Please indicate your understanding of this privacy statement by ticking the box!