Application for Assistance

Please ensure all sections of this form are completed and all relevant documentation is attached.

Complete the application online by filling out the form below. Or download the PDF version to fill out manually.

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Application For Assistance

Client Name: *

Client # *

Date of Birth *

Parent / Carer / Next of Kin: *

Relationship to child: *

Address *

Suburb *

Postcode *

Phone *

Email *

Name of person completing this form *

If not the parent or client, please have the family acknowledge the request via email to office@coastability.org.au

Name of Equipment /Provider Quotes *

Quotes Attached *

YES

File Upload *

Maximum file size: 134.22MB

Total expenditure to be undertaken (as per attached quote/s): *

Amount to be contributed by family: *

If you are unable to contribute to the costs please enter 0

Total Funding Amount Requested: $ *

Please attach report from Therapist

Type of therapist * Type of therapist

Attach Therapist Report *

Maximum file size: 134.22MB

Is Client Registered with the NDIS? *

YES

Has request been made to NDIS *

YES

Outcome Re Request: *

Please explain reason. *

Have you approached other sources for financial assistance e.g. Private Health Fund, local Service Club, etc.? *

YES

Name Of Organisation/s & Outcome *

Do you have Compensation? *

Yes

Extra Information: *

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