Therapeutic Services EOI

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Therapeutic Services Expression of Interest 2020

Date *

This form is being completed by: * Participant Carer Other Agency(s)

Carer Name:

Carer Phone

Carer Email:

Agency Name:

Contact Name:

Phone Number:

Contact Email:

Do you have a Carer? Yes No

Carers Name:

Carers Phone:

Carers Email:

Participant Name: *

Last Name: *

Date of Birth: *

Street Address:

Suburb:

Post Code:

Phone: *

Email:

Do you have a NDIS package? * Yes No

Have you applied for a NDIS package? Yes No

Please select the services you are interested in:

Everyday Wellbeing Group Art Therapy Group Sound Minds Group Counselling ME/CFS Wellbeing Group

Comments:

PLEASE NOTE: The facilitator of the group will contact you to explain the goal of that particular group, explore your needs and expectations and find out if this is the right program for you.

Address:
5 Cooke Terrace
Wayville SA 5034
Phone: (08) 8378 4100
ABN: 85 595 741 081

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