Request Service: If you are looking to engage with our services please use this form to start your journey with us. We will response to all enquiries during our office hours:
Monday &/or Friday between 9 - 1130am
Click the button below to start.
Question 1 of 26
Referrer Details - Include Full Name, Organisation, Phone Number & Email Address
Question 2 of 26
Who should we contact & how?
Question 3 of 26
Our Office Hours are:
When is the best time to make contact?
Monday 8 - 11 am
Tuesday 11 - 1
Wednesday 11 - 1
Thursday 8 - 11am
Friday 8 - 10 am
Question 4 of 26
Who is the client? Include full name, age, phone number, home address & email address
Question 5 of 26
Are we able to contact the client direct?
No client is a Child
Question 6 of 26
How will the client be paying for your service?
NDIS Self & Plan Managed
Other (workplace, agency)
Question 7 of 26
Trauma Sensitive Yoga Group Program
Support Work - 20 hours a month or more
Support Work - less than 20 hours a month
Yoga for Mental Health (yin yoga program)
Yoga Therapy - The Wild You Project
Question 8 of 26
Days Client is Available/Looking for Services
Question 9 of 26
Additional information around available time including time of day and frequency of service required
Question 10 of 26
Are there any Conditions/Diagnosis we should be aware of?
Question 11 of 26
Please outline any challenging behaviours including allergies, triggers, sensitivities
If you are currently a NDIS participant please complete the following information.
Question 13 of 26
Participants Full Name, Date Of Birth & NDIS Number
Question 14 of 26
If you are plan managed who is the plan manager? Who should invoices be directed to? If no plan managed leave blank or type self managed.
Question 15 of 26
Who is your coordinator of Supports include name, organisation name, phone number & email address (leave blank or type N/A if you currently do not have a COS)
Question 16 of 26
Current NDIS plan start & end date
Question 17 of 26
What budgets would you like to use? this helps us tailor make your program for you. ( you can choose one or both)
Question 18 of 26
NDIS Goal 1:
Question 19 of 26
NDIS Goal 2:
Question 20 of 26
NDIS Goal 3:
Question 21 of 26
NDIS Goal 4:
When requesting Yoga Therapy
please complete these additional questions
Question 23 of 26
Occupation (including tme i me in the current occupation. Please note prior occupation if there has been a change in the last few years.
Question 24 of 26
Yoga/Meditation/Mindfulness experience (including style of practice, outline daily/weekly practice schedule and years practicing)
Question 25 of 26
Do you (or have you ever suffered from)
Stress related tension
High Blood Pressure
Low Blood Pressure
Intervertebral disc problems
Question 26 of 26
If you ticked any on the last question please outline more information here