Intake form

Let's get you started

Five short steps - who you are, where you live, your people, your support, then sign. Skip anything you're not sure of; we'll fill the gaps together on the phone.

5 short steps Skip what you're not sure of Nothing is final until we've spoken

Your full name

Date of birth For example, 14 3 1986

Best contact number

Email (if you use it)

How do you prefer to hear from us? (optional)

Phone call Email FaceTime

Do you need an interpreter?

No Yes

Language spoken at home

Do you identify as: (optional) We ask so we can offer culturally safe support - it never affects access to services.

Aboriginal Torres Strait Islander

Street address

Suburb

Postcode

Is your postal address different?

No Yes

Postal address

Suburb

Postcode

Would you like an advocate or nominated person on this form?

No Yes

This person can speak with us on your behalf. You can change or remove them any time.

Their full name

Relationship to you

Their phone

Their email (if any)

Their authority starts from (if you'd like a date) Leave blank and it starts when we receive this form. For example, 1 8 2026

Is there a guardianship or administration order in place? For example, an order made by NCAT. "Not sure" is a fine answer.

No Yes Not sure

By signing, you confirm the information you've given is true to the best of your knowledge - and if you've nominated someone, you agree to the authority below.

If you've nominated someone - the authority to act

You authorise us to act on your nominated person's instructions
We're not responsible for their actions under this authority
It starts from the date you gave, or from when we receive this form - whichever is later
They can access your information by phone, email and letter
You can cancel any time by writing to us or calling - it takes effect once we receive it

Sign your way

Draw your signature, or type your name - both count equally as your signature.

Draw it Type my name

Sign here with your finger, mouse or stylus

Type your full name

Your typed name will appear here as your signature.

I intend this to be my signature on this form, and I understand it counts the same as signing on paper.

Check your answers

Nothing is sent yet - change anything you like first.

We only use these details to set up your supports - nothing else, no mailing lists.

Your intake form is with us

Thank you. Here's what happens next:

A real person reads it - it doesn't sit in a queue
We call you to arrange a first chat, at a time that suits you
Nothing is final until we've spoken - you stay in charge throughout