{"id":12,"date":"2025-07-09T17:49:09","date_gmt":"2025-07-09T17:49:09","guid":{"rendered":"https:\/\/disabilityservices247.com.au\/disabilityServiceForms\/?page_id=12"},"modified":"2025-07-18T08:11:34","modified_gmt":"2025-07-18T08:11:34","slug":"client-registration-form","status":"publish","type":"page","link":"https:\/\/disabilityservices247.com.au\/disabilityServiceForms\/client-registration-form\/","title":{"rendered":"Client Registration Form"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"12\" class=\"elementor elementor-12\" data-elementor-post-type=\"page\">\n\t\t\t\t<div class=\"elementor-element elementor-element-d9fe3a9 e-flex e-con-boxed e-con e-parent\" data-id=\"d9fe3a9\" data-element_type=\"container\" data-e-type=\"container\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-a4f42bd elementor-widget elementor-widget-shortcode\" data-id=\"a4f42bd\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"shortcode.default\">\n\t\t\t\t\t\t\t<div class=\"elementor-shortcode\">\n<div class=\"wpcf7 no-js\" id=\"wpcf7-f6-o1\" lang=\"en-US\" dir=\"ltr\" data-wpcf7-id=\"6\">\n<div class=\"screen-reader-response\"><p role=\"status\" aria-live=\"polite\" aria-atomic=\"true\"><\/p> <ul><\/ul><\/div>\n<form action=\"\/disabilityServiceForms\/wp-json\/wp\/v2\/pages\/12#wpcf7-f6-o1\" method=\"post\" class=\"wpcf7-form init\" aria-label=\"Contact form\" novalidate=\"novalidate\" data-status=\"init\">\n<fieldset class=\"hidden-fields-container\"><input type=\"hidden\" name=\"_wpcf7\" value=\"6\" \/><input type=\"hidden\" name=\"_wpcf7_version\" value=\"6.1.5\" \/><input type=\"hidden\" name=\"_wpcf7_locale\" value=\"en_US\" \/><input type=\"hidden\" name=\"_wpcf7_unit_tag\" value=\"wpcf7-f6-o1\" \/><input type=\"hidden\" name=\"_wpcf7_container_post\" value=\"0\" \/><input type=\"hidden\" name=\"_wpcf7_posted_data_hash\" value=\"\" \/>\n<\/fieldset>\n<div class=\"form_Sec\">\n\t<div class=\"formGroup\">\n\t\t<p><label>Client Name <span class=\"asteric\">*<\/span><\/label>\n\t\t<\/p>\n\t\t<div\n               class=\"twoCol justify-content-between align-items-center gap16\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"text-168\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required form-control\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"First name\" value=\"\" type=\"text\" name=\"text-168\" \/><\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"text-399\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required form-control\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Last name\" value=\"\" type=\"text\" name=\"text-399\" \/><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"formGroup\">\n\t\t<p><label>Date of Birth:<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"text-590\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text form-control\" aria-invalid=\"false\" placeholder=\"DD\/MM\/YYYY\" value=\"\" type=\"text\" name=\"text-590\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"formGroup\">\n\t\t<p><label>Registration Number:<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"text-551\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text form-control\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"text-551\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"formGroup\">\n\t\t<p><label>Type of NDIS Funding:<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"checkbox-747\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"checkbox-747[]\" value=\"Agency Managed\" \/><span class=\"wpcf7-list-item-label\">Agency Managed<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"checkbox-747[]\" value=\"Self Managed\" \/><span class=\"wpcf7-list-item-label\">Self Managed<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"checkbox-747[]\" value=\"Plan Managed\" \/><span class=\"wpcf7-list-item-label\">Plan Managed<\/span><\/label><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"formGroup\">\n\t\t<p><label>Specify Plan Manager (if applicable); refer to NDIS Funding<br \/>\nType<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"text-874\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text form-control\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"text-874\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"formGroup\">\n\t\t<p><label>Address<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"text-866\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text form-control\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"text-866\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"formGroup\">\n\t\t<p><label>Phone Number<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"tel-713\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-tel wpcf7-text wpcf7-validates-as-tel form-control\" aria-invalid=\"false\" value=\"\" type=\"tel\" name=\"tel-713\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"formGroup\">\n\t\t<p><label>Email<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"email-255\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-email wpcf7-text wpcf7-validates-as-email form-control\" aria-invalid=\"false\" value=\"\" type=\"email\" name=\"email-255\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"formGroup\">\n\t\t<p><label>Preferred Contact Method<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"checkbox-381\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"checkbox-381[]\" value=\"Phone\" \/><span class=\"wpcf7-list-item-label\">Phone<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"checkbox-381[]\" value=\"Email\" \/><span class=\"wpcf7-list-item-label\">Email<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"checkbox-381[]\" value=\"Mail\" \/><span class=\"wpcf7-list-item-label\">Mail<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"checkbox-381[]\" value=\"SMS\" \/><span class=\"wpcf7-list-item-label\">SMS<\/span><\/label><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n<hr class=\"w-100\" \/>\n\t<h3>Representative or Emergency Contact Information\n\t<\/h3>\n\t<div class=\"formGroup\">\n\t\t<p><label>Name <span class=\"asteric\">*<\/span><\/label>\n\t\t<\/p>\n\t\t<div\n               class=\"twoCol justify-content-between align-items-center gap16\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"text-438\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required form-control\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"First name\" value=\"\" type=\"text\" name=\"text-438\" \/><\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"text-995\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required form-control\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Last name\" value=\"\" type=\"text\" name=\"text-995\" \/><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"formGroup\">\n\t\t<p><label>Client Relationship<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"text-618\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text form-control\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"text-618\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"formGroup\">\n\t\t<p><label>Address<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"text-845\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text form-control\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"text-845\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"formGroup\">\n\t\t<p><label>Phone Number<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"text-341\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text form-control\" aria-invalid=\"false\" placeholder=\"xxxx xxxxxxx\" value=\"\" type=\"text\" name=\"text-341\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"formGroup\">\n\t\t<p><label>Email <span class=\"asteric\">*<\/span><\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"email-449\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-email wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-email form-control\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"email\" name=\"email-449\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"formGroup\">\n\t\t<p><label>Preferred Contact Preference<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"checkbox-915\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"checkbox-915[]\" value=\"Phone\" \/><span class=\"wpcf7-list-item-label\">Phone<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"checkbox-915[]\" value=\"Email\" \/><span class=\"wpcf7-list-item-label\">Email<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"checkbox-915[]\" value=\"Mail\" \/><span class=\"wpcf7-list-item-label\">Mail<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"checkbox-915[]\" value=\"SMS\" \/><span class=\"wpcf7-list-item-label\">SMS<\/span><\/label><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<h3>About you\n\t<\/h3>\n\t<div class=\"formGroup\">\n\t\t<p><label>Living Arrangements<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"checkbox-52\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"checkbox-52[]\" value=\"Living Independently (Solo)\" \/><span class=\"wpcf7-list-item-label\">Living Independently (Solo)<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"checkbox-52[]\" value=\"Living with Family in Own Home\" \/><span class=\"wpcf7-list-item-label\">Living with Family in Own Home<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"checkbox-52[]\" value=\"Assisted Living Arrangements\" \/><span class=\"wpcf7-list-item-label\">Assisted Living Arrangements<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"checkbox-52[]\" value=\"Temporary\" \/><span class=\"wpcf7-list-item-label\">Temporary<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"checkbox-52[]\" value=\"Other\" \/><span class=\"wpcf7-list-item-label\">Other<\/span><\/label><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"formGroup\">\n\t\t<p><label>Are you of Aboriginal or Torres Strait Islander<br \/>\ndescent?<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"radio-714\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"radio-714\" value=\"Please select\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">Please select<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"radio\" name=\"radio-714\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"radio-714\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"formGroup\">\n\t\t<p><label>Does the Client Currently Have a Behavioral Support<br \/>\nPlan?<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"radio-186\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"radio-186\" value=\"Please select\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">Please select<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"radio\" name=\"radio-186\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"radio-186\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"formGroup\">\n\t\t<p><label>Main Formal Diagnosis<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"text-67\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text form-control\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"text-67\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"formGroup\">\n\t\t<p><label>Secondary Formal Diagnosis<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"text-552\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text form-control\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"text-552\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"formGroup\">\n\t\t<p><label>Do you have any allergies? If so, please specify<br \/>\nbelow.<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"text-449\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text form-control\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"text-449\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"formGroup\">\n\t\t<p><label>Please list all medical diagnoses and medications that may<br \/>\nimpact the support provided.<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"text-225\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text form-control\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"text-225\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"formGroup\">\n\t\t<p><label>Please provide the name and contact number of the client's<br \/>\ndoctor.<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"text-669\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text form-control\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"text-669\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"formGroup\">\n\t\t<p><label>Please disclose any legal issues that may impact the service,<br \/>\nsuch as Apprehended Violence Orders.<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"text-242\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text form-control\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"text-242\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"formGroup\">\n\t\t<p><label>Type<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"radio-916\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"radio-916\" value=\"Please select\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">Please select<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"radio\" name=\"radio-916\" value=\"Verbal\" \/><span class=\"wpcf7-list-item-label\">Verbal<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"radio\" name=\"radio-916\" value=\"Non-Verbal\" \/><span class=\"wpcf7-list-item-label\">Non-Verbal<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"radio\" name=\"radio-916\" value=\"Required Communication Aids\" \/><span class=\"wpcf7-list-item-label\">Required Communication Aids<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"radio-916\" value=\"Other\" \/><span class=\"wpcf7-list-item-label\">Other<\/span><\/label><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"formGroup\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"text-829\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text form-control\" aria-invalid=\"false\" placeholder=\"Other Type\" value=\"\" type=\"text\" name=\"text-829\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"formGroup\">\n\t\t<p><label>Are you from a culturally or linguistically diverse<br \/>\nbackground?<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"radio-175\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"radio-175\" value=\"Please select\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">Please select<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"radio\" name=\"radio-175\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"radio-175\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"formGroup\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"text-192\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text form-control\" aria-invalid=\"false\" placeholder=\"Details\" value=\"\" type=\"text\" name=\"text-192\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"formGroup\">\n\t\t<p><label>Is there any cultural diversity, values, or beliefs you'd<br \/>\nlike us to be aware of?<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"radio-899\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"radio-899\" value=\"Please select\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">Please select<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"radio\" name=\"radio-899\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"radio-899\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"formGroup\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"text-573\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text form-control\" aria-invalid=\"false\" placeholder=\"Details\" value=\"\" type=\"text\" name=\"text-573\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"formGroup\">\n\t\t<p><label>Languages Spoken<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"checkbox-622\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"checkbox-622[]\" value=\"English\" \/><span class=\"wpcf7-list-item-label\">English<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"checkbox-622[]\" value=\"Other\" \/><span class=\"wpcf7-list-item-label\">Other<\/span><\/label><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"formGroup\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"text-896\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text form-control\" aria-invalid=\"false\" placeholder=\"Other Language\" value=\"\" type=\"text\" name=\"text-896\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"formGroup\">\n\t\t<p><label>Is an interpreter needed?<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"checkbox-98\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"checkbox-98[]\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"checkbox-98[]\" value=\"Hearing Impaired\" \/><span class=\"wpcf7-list-item-label\">Hearing Impaired<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"checkbox-98[]\" value=\"Language\" \/><span class=\"wpcf7-list-item-label\">Language<\/span><\/label><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"formGroup\">\n\t\t<p><label>Are you willing to participate in and consent to the use<br \/>\nof...<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"checkbox-262\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"checkbox-262[]\" value=\"Goal Data Photos\" \/><span class=\"wpcf7-list-item-label\">Goal Data Photos<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"checkbox-262[]\" value=\"Social Media Photos\" \/><span class=\"wpcf7-list-item-label\">Social Media Photos<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"checkbox-262[]\" value=\"Website Photos\" \/><span class=\"wpcf7-list-item-label\">Website Photos<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"checkbox-262[]\" value=\"Participating in audits conducted by the NDIS Commission for our business, including...\" \/><span class=\"wpcf7-list-item-label\">Participating in audits conducted by the NDIS Commission for our business, including...<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"checkbox-262[]\" value=\"its auditors\" \/><span class=\"wpcf7-list-item-label\">its auditors<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"checkbox-262[]\" value=\"The recording of your personal information in audio and\/or visual format\" \/><span class=\"wpcf7-list-item-label\">The recording of your personal information in audio and\/or visual format<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"checkbox-262[]\" value=\"None of the above\" \/><span class=\"wpcf7-list-item-label\">None of the above<\/span><\/label><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<h3 class=\"w-100\">Dietary Needs\n\t<\/h3>\n\t<h5 class=\"w-100 my-2\">I have the following allergies\/intolerances, and<br \/>\nmy favorite food is...\n\t<\/h5>\n\t<div class=\"formGroup\">\n\t\t<p><label>No Dietary Needs<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"checkbox-687\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"checkbox-687[]\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"checkbox-687[]\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"formGroup\">\n\t\t<p><label>Vegetarian<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"checkbox-985\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"checkbox-985[]\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"checkbox-985[]\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"formGroup\">\n\t\t<p><label>Vegan<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"checkbox-827\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"checkbox-827[]\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"checkbox-827[]\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"formGroup\">\n\t\t<p><label>I have allergies to (please list)<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"textarea-375\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea form-control\" aria-invalid=\"false\" name=\"textarea-375\"><\/textarea><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"formGroup\">\n\t\t<p><label>I cannot consume (sensory\/intolerances)<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"textarea-757\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea form-control\" aria-invalid=\"false\" name=\"textarea-757\"><\/textarea><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"formGroup\">\n\t\t<p><label>My favourite food is\u2026<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"textarea-548\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea form-control\" aria-invalid=\"false\" name=\"textarea-548\"><\/textarea><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"formGroup\">\n\t\t<p><label>Disability Services 24\/7 can assist me during mealtimes<br \/>\nby...<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"checkbox-686\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"checkbox-686[]\" value=\"I can identify which foods are safe for me to eat (if required due to allergy or dietary requirements).\" \/><span class=\"wpcf7-list-item-label\">I can identify which foods are safe for me to eat (if required due to allergy or dietary requirements).<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"checkbox-686[]\" value=\"If I have a food allergy, I have provided Disability Services 24\/7 with a management plan.\" \/><span class=\"wpcf7-list-item-label\">If I have a food allergy, I have provided Disability Services 24\/7 with a management plan.<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"checkbox-686[]\" value=\"If necessary, I will bring any medications to assist with my allergy and have completed the relevant medical forms.\" \/><span class=\"wpcf7-list-item-label\">If necessary, I will bring any medications to assist with my allergy and have completed the relevant medical forms.<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"checkbox-686[]\" value=\"I prefer to provide my own food and will do so.\" \/><span class=\"wpcf7-list-item-label\">I prefer to provide my own food and will do so.<\/span><\/label><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<h3>Mental Well-being\n\t<\/h3>\n\t<div class=\"formGroup\">\n\t\t<p><label>I have\/experience\u2026<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"checkbox-650\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"checkbox-650[]\" value=\"Depression\" \/><span class=\"wpcf7-list-item-label\">Depression<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"checkbox-650[]\" value=\"Anxiety\" \/><span class=\"wpcf7-list-item-label\">Anxiety<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"checkbox-650[]\" value=\"Psychosis\" \/><span class=\"wpcf7-list-item-label\">Psychosis<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"checkbox-650[]\" value=\"Schizophrenia\" \/><span class=\"wpcf7-list-item-label\">Schizophrenia<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"checkbox-650[]\" value=\"Bipolar\" \/><span class=\"wpcf7-list-item-label\">Bipolar<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"checkbox-650[]\" value=\"Other\" \/><span class=\"wpcf7-list-item-label\">Other<\/span><\/label><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"formGroup\">\n\t\t<p><label>I would like Disability Services 24\/7 to assist me in<br \/>\nmanaging this by...<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"textarea-628\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea form-control\" aria-invalid=\"false\" name=\"textarea-628\"><\/textarea><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"formGroup\">\n\t\t<p><label>My triggers may include\u2026<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"textarea-589\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea form-control\" aria-invalid=\"false\" name=\"textarea-589\"><\/textarea><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"formGroup\">\n\t\t<p><label>I am supported\/linked with the following organizations who<br \/>\nassist me... (Please supply relevant management plans.)<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"textarea-310\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea form-control\" aria-invalid=\"false\" name=\"textarea-310\"><\/textarea><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"formGroup\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"checkbox-804\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first last\"><label><input type=\"checkbox\" name=\"checkbox-804[]\" value=\"I have received medical support to assist me, and Disability Services 24\/7 has a copy of any relevant management plans to help me manage.\" \/><span class=\"wpcf7-list-item-label\">I have received medical support to assist me, and Disability Services 24\/7 has a copy of any relevant management plans to help me manage.<\/span><\/label><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<h3>Physical Well-being\n\t<\/h3>\n\t<div class=\"formGroup\">\n\t\t<p><label>I have\u2026<\/label>\n\t\t<\/p>\n\t\t<div class=\"d-grid col6\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"checkbox-945\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"checkbox-945[]\" value=\"Diabetes\" \/><span class=\"wpcf7-list-item-label\">Diabetes<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"checkbox-945[]\" value=\"Epilepsy\" \/><span class=\"wpcf7-list-item-label\">Epilepsy<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"checkbox-945[]\" value=\"Asthma\" \/><span class=\"wpcf7-list-item-label\">Asthma<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"checkbox-945[]\" value=\"Visual Impairment\" \/><span class=\"wpcf7-list-item-label\">Visual Impairment<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"checkbox-945[]\" value=\"Cognitive Challenges\" \/><span class=\"wpcf7-list-item-label\">Cognitive Challenges<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"checkbox-945[]\" value=\"Other\" \/><span class=\"wpcf7-list-item-label\">Other<\/span><\/label><\/span><\/span><\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"checkbox-365\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"checkbox-365[]\" value=\"Sleep Apnoea\" \/><span class=\"wpcf7-list-item-label\">Sleep Apnoea<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"checkbox-365[]\" value=\"Dietary Requirements\" \/><span class=\"wpcf7-list-item-label\">Dietary Requirements<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"checkbox-365[]\" value=\"Blood Disorders\" \/><span class=\"wpcf7-list-item-label\">Blood Disorders<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"checkbox-365[]\" value=\"Hearing Impairment\" \/><span class=\"wpcf7-list-item-label\">Hearing Impairment<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"checkbox-365[]\" value=\"Heart Conditions\" \/><span class=\"wpcf7-list-item-label\">Heart Conditions<\/span><\/label><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"formGroup\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"text-836\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text form-control\" aria-invalid=\"false\" placeholder=\"Other\" value=\"\" type=\"text\" name=\"text-836\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"formGroup\">\n\t\t<p><label>Allergies to:<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"text-328\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text form-control\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"text-328\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"formGroup\">\n\t\t<p><label>I am taking the following medications:<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"textarea-223\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea form-control\" aria-invalid=\"false\" name=\"textarea-223\"><\/textarea><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"formGroup\">\n\t\t<p><label>Medication List:<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"textarea-medication-list\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea form-control\" aria-invalid=\"false\" name=\"textarea-medication-list\"><\/textarea><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"formGroup\">\n\t\t<p><label>I would like Disability Services 24\/7 to assist me in managing this by...<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"textarea-manage-support\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea form-control\" aria-invalid=\"false\" name=\"textarea-manage-support\"><\/textarea><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<h3>Please select the boxes that best represent you and your support needs:\n\t<\/h3>\n\t<div class=\"formGroup\">\n\t\t<p><label>Traffic awareness<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"traf1\"><span class=\"wpcf7-form-control wpcf7-checkbox d-flex justify-content-between\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"traf1[]\" value=\"I can do independently\" \/><span class=\"wpcf7-list-item-label\">I can do independently<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"traf1[]\" value=\"I need some assistance.\" \/><span class=\"wpcf7-list-item-label\">I need some assistance.<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"traf1[]\" value=\"I cannot do independently\" \/><span class=\"wpcf7-list-item-label\">I cannot do independently<\/span><\/label><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"formGroup\">\n\t\t<p><label>Staying with the group<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"stay1\"><span class=\"wpcf7-form-control wpcf7-checkbox d-flex justify-content-between\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"stay1[]\" value=\"I can do independently\" \/><span class=\"wpcf7-list-item-label\">I can do independently<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"stay1[]\" value=\"I need some assistance.\" \/><span class=\"wpcf7-list-item-label\">I need some assistance.<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"stay1[]\" value=\"I cannot do independently\" \/><span class=\"wpcf7-list-item-label\">I cannot do independently<\/span><\/label><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"formGroup\">\n\t\t<p><label>Appropriate Communication<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"comm1\"><span class=\"wpcf7-form-control wpcf7-checkbox d-flex justify-content-between\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"comm1[]\" value=\"I can do independently\" \/><span class=\"wpcf7-list-item-label\">I can do independently<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"comm1[]\" value=\"I need some assistance.\" \/><span class=\"wpcf7-list-item-label\">I need some assistance.<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"comm1[]\" value=\"I cannot do independently\" \/><span class=\"wpcf7-list-item-label\">I cannot do independently<\/span><\/label><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"formGroup\">\n\t\t<p><label>Personal Space Awareness<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"spac1\"><span class=\"wpcf7-form-control wpcf7-checkbox d-flex justify-content-between\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"spac1[]\" value=\"I can do independently\" \/><span class=\"wpcf7-list-item-label\">I can do independently<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"spac1[]\" value=\"I need some assistance.\" \/><span class=\"wpcf7-list-item-label\">I need some assistance.<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"spac1[]\" value=\"I cannot do independently\" \/><span class=\"wpcf7-list-item-label\">I cannot do independently<\/span><\/label><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"formGroup\">\n\t\t<p><label>Respecting Personal Boundaries<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"hand1\"><span class=\"wpcf7-form-control wpcf7-checkbox d-flex justify-content-between\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"hand1[]\" value=\"I can do independently\" \/><span class=\"wpcf7-list-item-label\">I can do independently<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"hand1[]\" value=\"I need some assistance.\" \/><span class=\"wpcf7-list-item-label\">I need some assistance.<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"hand1[]\" value=\"I cannot do independently\" \/><span class=\"wpcf7-list-item-label\">I cannot do independently<\/span><\/label><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"formGroup\">\n\t\t<p><label>Safe Car Travel<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"travel1\"><span class=\"wpcf7-form-control wpcf7-checkbox d-flex justify-content-between\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"travel1[]\" value=\"I can do independently\" \/><span class=\"wpcf7-list-item-label\">I can do independently<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"travel1[]\" value=\"I need some assistance.\" \/><span class=\"wpcf7-list-item-label\">I need some assistance.<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"travel1[]\" value=\"I cannot do independently\" \/><span class=\"wpcf7-list-item-label\">I cannot do independently<\/span><\/label><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"formGroup\">\n\t\t<p><label>Following Instructions<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"inst1\"><span class=\"wpcf7-form-control wpcf7-checkbox d-flex justify-content-between\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"inst1[]\" value=\"I can do independently\" \/><span class=\"wpcf7-list-item-label\">I can do independently<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"inst1[]\" value=\"I need some assistance.\" \/><span class=\"wpcf7-list-item-label\">I need some assistance.<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"inst1[]\" value=\"I cannot do independently\" \/><span class=\"wpcf7-list-item-label\">I cannot do independently<\/span><\/label><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"formGroup\">\n\t\t<p><label>Swimming and Water Safety<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"swim1\"><span class=\"wpcf7-form-control wpcf7-checkbox d-flex justify-content-between\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"swim1[]\" value=\"I can do independently\" \/><span class=\"wpcf7-list-item-label\">I can do independently<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"swim1[]\" value=\"I need some assistance.\" \/><span class=\"wpcf7-list-item-label\">I need some assistance.<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"swim1[]\" value=\"I cannot do independently\" \/><span class=\"wpcf7-list-item-label\">I cannot do independently<\/span><\/label><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"formGroup\">\n\t\t<p><label>I can manage my own spending money.<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"mon1\"><span class=\"wpcf7-form-control wpcf7-checkbox d-flex justify-content-between\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"mon1[]\" value=\"I can do independently\" \/><span class=\"wpcf7-list-item-label\">I can do independently<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"mon1[]\" value=\"I need some assistance.\" \/><span class=\"wpcf7-list-item-label\">I need some assistance.<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"mon1[]\" value=\"I cannot do independently\" \/><span class=\"wpcf7-list-item-label\">I cannot do independently<\/span><\/label><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"formGroup\">\n\t\t<p><label>I am comfortable with my sleeping routine.<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"rout1\"><span class=\"wpcf7-form-control wpcf7-checkbox d-flex justify-content-between\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"rout1[]\" value=\"I can do independently\" \/><span class=\"wpcf7-list-item-label\">I can do independently<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"rout1[]\" value=\"I need some assistance.\" \/><span class=\"wpcf7-list-item-label\">I need some assistance.<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"rout1[]\" value=\"I cannot do independently\" \/><span class=\"wpcf7-list-item-label\">I cannot do independently<\/span><\/label><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"formGroup\">\n\t\t<p><label>Swimming and Water Safety<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"checkbox-699\"><span class=\"wpcf7-form-control wpcf7-checkbox d-flex justify-content-between\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"checkbox-699[]\" value=\"I can do independently\" \/><span class=\"wpcf7-list-item-label\">I can do independently<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"checkbox-699[]\" value=\"I need some assistance.\" \/><span class=\"wpcf7-list-item-label\">I need some assistance.<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"checkbox-699[]\" value=\"I cannot do independently\" \/><span class=\"wpcf7-list-item-label\">I cannot do independently<\/span><\/label><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"formGroup\">\n\t\t<p><label>Disability Services 24\/7 can assist me by\u2026<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"prac-sup\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea form-control\" aria-invalid=\"false\" name=\"prac-sup\"><\/textarea><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"formGroup\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"help-sup\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first last\"><label><input type=\"checkbox\" name=\"help-sup[]\" value=\"I have provided Disability Services 24\/7 with any relevant behavior plans for assisting me when required.\" \/><span class=\"wpcf7-list-item-label\">I have provided Disability Services 24\/7 with any relevant behavior plans for assisting me when required.<\/span><\/label><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<p>Tell us a bit about yourself and your goals. To help us understand you better, please fill out the form below:\n\t<\/p>\n\t<div class=\"formGroup\">\n\t\t<p><label>My strengths are (what I am good at)\u2026<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"stren\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea form-control\" aria-invalid=\"false\" name=\"stren\"><\/textarea><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"formGroup\">\n\t\t<p><label>I like\u2026<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"likes\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea form-control\" aria-invalid=\"false\" name=\"likes\"><\/textarea><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"formGroup\">\n\t\t<p><label>I don\u2019t like\u2026 (please include any sensory considerations)<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"unlikes\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea form-control\" aria-invalid=\"false\" name=\"unlikes\"><\/textarea><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"formGroup\">\n\t\t<p><label>You will know when I am happy by\u2026<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"hapy\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea form-control\" aria-invalid=\"false\" name=\"hapy\"><\/textarea><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"formGroup\">\n\t\t<p><label>You will know when I am unhappy by\u2026<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"unhapy\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea form-control\" aria-invalid=\"false\" name=\"unhapy\"><\/textarea><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"formGroup\">\n\t\t<p><label>I prefer to communicate by\u2026<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"pre-com\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea form-control\" aria-invalid=\"false\" name=\"pre-com\"><\/textarea><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"formGroup\">\n\t\t<p><label>How have these goals changed since your previous Support Plan (if applicable)?<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"prev-sup\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea form-control\" aria-invalid=\"false\" name=\"prev-sup\"><\/textarea><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"formGroup\">\n\t\t<p><label>How does your existing support from us or other providers help achieve desired outcomes? Is there any opportunity to use less intrusive options, in accordance with contemporary evidence-informed practices that meet participant needs and help achieve desired outcomes?<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"achieve\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea form-control\" aria-invalid=\"false\" name=\"achieve\"><\/textarea><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<h3>Health requirements\n\t<\/h3>\n\t<div class=\"formGroup\">\n\t\t<p><label>Activity<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"checkbox-414\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"checkbox-414[]\" value=\"Continence with regular bowel and bladder function\" \/><span class=\"wpcf7-list-item-label\">Continence with regular bowel and bladder function<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"checkbox-414[]\" value=\"Management of Constipation, Diarrhea, or Incontinence (including medication, supplements, pads)\" \/><span class=\"wpcf7-list-item-label\">Management of Constipation, Diarrhea, or Incontinence (including medication, supplements, pads)<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"checkbox-414[]\" value=\"Medical Interventions (such as catheter, stoma bag)\" \/><span class=\"wpcf7-list-item-label\">Medical Interventions (such as catheter, stoma bag)<\/span><\/label><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"formGroup\">\n\t\t<p><label>Outline the condition, treatments, aids\/assistance required, who will provide them, and when.<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"textarea-380\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea form-control\" aria-invalid=\"false\" name=\"textarea-380\"><\/textarea><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"formGroup\">\n\t\t<p><label>Skin Health<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"checkbox-166\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"checkbox-166[]\" value=\"No Skin Issues\" \/><span class=\"wpcf7-list-item-label\">No Skin Issues<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"checkbox-166[]\" value=\"Minor Skin Issues (rash, skin treatments)\" \/><span class=\"wpcf7-list-item-label\">Minor Skin Issues (rash, skin treatments)<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"checkbox-166[]\" value=\"Pressure Sores (current, at risk, or history)\" \/><span class=\"wpcf7-list-item-label\">Pressure Sores (current, at risk, or history)<\/span><\/label><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"formGroup\">\n\t\t<p><label>Please outline the condition, required treatments, aids\/assistance needed, who will provide them, and when.<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"textarea-375\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea form-control\" aria-invalid=\"false\" name=\"textarea-375\"><\/textarea><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"formGroup\">\n\t\t<p><label>Swallowing Function<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"checkbox-413\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"checkbox-413[]\" value=\"No Swallowing Difficulties\" \/><span class=\"wpcf7-list-item-label\">No Swallowing Difficulties<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"checkbox-413[]\" value=\"Minor Swallowing Issues (choking, coughing during meals, reduced appetite)\" \/><span class=\"wpcf7-list-item-label\">Minor Swallowing Issues (choking, coughing during meals, reduced appetite)<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"checkbox-413[]\" value=\"Severe Swallowing Difficulties (modified diet, feeding tube)\" \/><span class=\"wpcf7-list-item-label\">Severe Swallowing Difficulties (modified diet, feeding tube)<\/span><\/label><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"formGroup\">\n\t\t<p><label>Please outline the condition, required treatments, aids\/assistance needed, who will provide them, and when.<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"textarea-983\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea form-control\" aria-invalid=\"false\" name=\"textarea-983\"><\/textarea><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"formGroup\">\n\t\t<p><label>Healthcare Professionals<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"checkbox-171\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"checkbox-171[]\" value=\"Received a GP check-up in the last 12 months\" \/><span class=\"wpcf7-list-item-label\">Received a GP check-up in the last 12 months<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"checkbox-171[]\" value=\"Regularly visit a specialist\" \/><span class=\"wpcf7-list-item-label\">Regularly visit a specialist<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"checkbox-171[]\" value=\"Have a Case Manager\/Support Coordinator\" \/><span class=\"wpcf7-list-item-label\">Have a Case Manager\/Support Coordinator<\/span><\/label><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"formGroup\">\n\t\t<p><label>Please outline the condition, required treatments, aids\/assistance needed, who will provide them, and when.<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"textarea-749\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea form-control\" aria-invalid=\"false\" name=\"textarea-749\"><\/textarea><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"formGroup\">\n\t\t<p><label>Muscular pain<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"checkbox-577\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"checkbox-577[]\" value=\"No pain\" \/><span class=\"wpcf7-list-item-label\">No pain<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"checkbox-577[]\" value=\"Moderate Pain\" \/><span class=\"wpcf7-list-item-label\">Moderate Pain<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"checkbox-577[]\" value=\"Severe Pain\" \/><span class=\"wpcf7-list-item-label\">Severe Pain<\/span><\/label><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"formGroup\">\n\t\t<p><label>Please outline the condition, required treatments, aids\/assistance needed, who will provide them, and when.<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"textarea-12\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea form-control\" aria-invalid=\"false\" name=\"textarea-12\"><\/textarea><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"formGroup\">\n\t\t<p><label>Nerve pain<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"checkbox-565\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"checkbox-565[]\" value=\"No Pain\" \/><span class=\"wpcf7-list-item-label\">No Pain<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"checkbox-565[]\" value=\"Moderate Pain\" \/><span class=\"wpcf7-list-item-label\">Moderate Pain<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"checkbox-565[]\" value=\"Severe Pain\" \/><span class=\"wpcf7-list-item-label\">Severe Pain<\/span><\/label><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"formGroup\">\n\t\t<p><label>Please outline the condition, required treatments, aids\/assistance needed, who will provide them, and when.<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"textarea-558\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea form-control\" aria-invalid=\"false\" name=\"textarea-558\"><\/textarea><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"formGroup\">\n\t\t<p><label>Falls Risk<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"checkbox-646\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"checkbox-646[]\" value=\"No Falls in Past 12 Months\" \/><span class=\"wpcf7-list-item-label\">No Falls in Past 12 Months<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"checkbox-646[]\" value=\"Less Than 3 Falls with No Serious Injury in the Past 12 Months\" \/><span class=\"wpcf7-list-item-label\">Less Than 3 Falls with No Serious Injury in the Past 12 Months<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"checkbox-646[]\" value=\"More Than 3 Falls or Serious Injury from a Fall in the Past Year\" \/><span class=\"wpcf7-list-item-label\">More Than 3 Falls or Serious Injury from a Fall in the Past Year<\/span><\/label><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"formGroup\">\n\t\t<p><label>Please provide details of the condition, necessary treatments, required aids\/assistance, who will provide them, and when.<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"textarea-645\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea form-control\" aria-invalid=\"false\" name=\"textarea-645\"><\/textarea><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"formGroup\">\n\t\t<p><label>Muscle-related Issues (excluding pain)<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"checkbox-783\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"checkbox-783[]\" value=\"No problems\" \/><span class=\"wpcf7-list-item-label\">No problems<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"checkbox-783[]\" value=\"Muscle Weakness, Tremors, Spasms, Spasticity, or Balance Issues\" \/><span class=\"wpcf7-list-item-label\">Muscle Weakness, Tremors, Spasms, Spasticity, or Balance Issues<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"checkbox-783[]\" value=\"Severe Muscle Weakness, Tremors, Spasticity, or Balance Issues\" \/><span class=\"wpcf7-list-item-label\">Severe Muscle Weakness, Tremors, Spasticity, or Balance Issues<\/span><\/label><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"formGroup\">\n\t\t<p><label>Please provide details of the condition, necessary treatments, required aids\/assistance, who will provide them, and when.<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"textarea-757\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea form-control\" aria-invalid=\"false\" name=\"textarea-757\"><\/textarea><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"formGroup\">\n\t\t<p><label>Other Health Issues<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"checkbox-156\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"checkbox-156[]\" value=\"Fatigue\" \/><span class=\"wpcf7-list-item-label\">Fatigue<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"checkbox-156[]\" value=\"Visual Disturbance\" \/><span class=\"wpcf7-list-item-label\">Visual Disturbance<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"checkbox-156[]\" value=\"Temperature Intolerance\" \/><span class=\"wpcf7-list-item-label\">Temperature Intolerance<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"checkbox-156[]\" value=\"Other Medical Conditions\" \/><span class=\"wpcf7-list-item-label\">Other Medical Conditions<\/span><\/label><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"formGroup\">\n\t\t<p><label>Please provide details of the condition, necessary treatments, required aids\/assistance, who will provide them, and when.<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"textarea-757\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea form-control\" aria-invalid=\"false\" name=\"textarea-757\"><\/textarea><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<h4>Social Needs\n\t<\/h4>\n\t<h3>Family:\n\t<\/h3>\n\t<div class=\"formGroup\">\n\t\t<p><label>Describe how you would like to engage in this activity.<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"textarea-24\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea form-control\" aria-invalid=\"false\" name=\"textarea-24\"><\/textarea><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"formGroup\">\n\t\t<p><label>Please provide details of the activity, including the time spent, assistance required, who will provide it, and when (including vouchers).<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"textarea-522\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea form-control\" aria-invalid=\"false\" name=\"textarea-522\"><\/textarea><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<h3>Hobbies & Interests:\n\t<\/h3>\n\t<div class=\"formGroup\">\n\t\t<p><label>Describe how you would like to engage in this activity.<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"textarea-248\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea form-control\" aria-invalid=\"false\" name=\"textarea-248\"><\/textarea><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"formGroup\">\n\t\t<p><label>Please provide details of the activity, including the time spent, assistance required, who will provide it, and when (including vouchers).<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"textarea-279\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea form-control\" aria-invalid=\"false\" name=\"textarea-279\"><\/textarea><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<h3>Religion & spirituality:\n\t<\/h3>\n\t<div class=\"formGroup\">\n\t\t<p><label>Please describe how you would like to engage in this activity.<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"textarea-406\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea form-control\" aria-invalid=\"false\" name=\"textarea-406\"><\/textarea><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"formGroup\">\n\t\t<p><label>Please provide details of the activity, including the time spent, assistance required, who will provide it, and when (including vouchers).<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"textarea-312\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea form-control\" aria-invalid=\"false\" name=\"textarea-312\"><\/textarea><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<h3>Outings: For example, theatre, cafes, exhibitions, drives, group activities.\n\t<\/h3>\n\t<div class=\"formGroup\">\n\t\t<p><label>Describe how you would like to engage in this activity.<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"textarea-782\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea form-control\" aria-invalid=\"false\" name=\"textarea-782\"><\/textarea><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"formGroup\">\n\t\t<p><label>Provide details of the activity, the time spent, the assistance required, from whom and when (including vouchers)<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"textarea-256\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea form-control\" aria-invalid=\"false\" name=\"textarea-256\"><\/textarea><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<h3>Computer Activities: Such as games, shopping, education, bookings\n\t<\/h3>\n\t<div class=\"formGroup\">\n\t\t<p><label>Outline how you want to engage in this activity<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"textarea-606\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea form-control\" aria-invalid=\"false\" name=\"textarea-606\"><\/textarea><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"formGroup\">\n\t\t<p><label>Provide details of the activity, the time spent, the assistance required, from whom and when (including vouchers)<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"textarea-560\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea form-control\" aria-invalid=\"false\" name=\"textarea-560\"><\/textarea><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<h3>Employment and Education\n\t<\/h3>\n\t<div class=\"formGroup\">\n\t\t<p><label>Outline how you want to engage in this activity<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"textarea-587\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea form-control\" aria-invalid=\"false\" name=\"textarea-587\"><\/textarea><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"formGroup\">\n\t\t<p><label>Provide details of the activity, the time spent, the assistance required, from whom and when (including vouchers)<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"textarea-154\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea form-control\" aria-invalid=\"false\" name=\"textarea-154\"><\/textarea><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<h3>Sports Activities\n\t<\/h3>\n\t<div class=\"formGroup\">\n\t\t<p><label>Outline how you want to engage in this activity<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"textarea-443\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea form-control\" aria-invalid=\"false\" name=\"textarea-443\"><\/textarea><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"formGroup\">\n\t\t<p><label>Provide details of the activity, the time spent, the assistance required, from whom and when (including vouchers)<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"textarea-524\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea form-control\" aria-invalid=\"false\" name=\"textarea-524\"><\/textarea><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<h3>Music Preferences\n\t<\/h3>\n\t<div class=\"formGroup\">\n\t\t<p><label>Outline how you want to engage in this activity<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"textarea-786\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea form-control\" aria-invalid=\"false\" name=\"textarea-786\"><\/textarea><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"formGroup\">\n\t\t<p><label>Provide details of the activity, the time spent, the assistance required, from whom and when (including vouchers)<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"textarea-116\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea form-control\" aria-invalid=\"false\" name=\"textarea-116\"><\/textarea><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<h3>Movies\/TV Preferences\n\t<\/h3>\n\t<div class=\"formGroup\">\n\t\t<p><label>Outline how you want to engage in this activity<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"textarea-534\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea form-control\" aria-invalid=\"false\" name=\"textarea-534\"><\/textarea><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"formGroup\">\n\t\t<p><label>Provide details of the activity, the time spent, the assistance required, from whom and when (including vouchers)<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"textarea-189\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea form-control\" aria-invalid=\"false\" name=\"textarea-189\"><\/textarea><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<h3>Well-being Activities: Such as exercise, gym, swimming, massage, yoga, meditation\n\t<\/h3>\n\t<div class=\"formGroup\">\n\t\t<p><label>Outline how you want to engage in this activity<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"textarea-986\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea form-control\" aria-invalid=\"false\" name=\"textarea-986\"><\/textarea><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"formGroup\">\n\t\t<p><label>Provide details of the activity, the time spent, the assistance required, from whom and when (including vouchers)<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"textarea-554\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea form-control\" aria-invalid=\"false\" name=\"textarea-554\"><\/textarea><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<h3>Food and Alcohol Preferences: Including likes, dislikes, and diets\n\t<\/h3>\n\t<div class=\"formGroup\">\n\t\t<p><label>Outline how you want to engage in this activity<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"textarea-467\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea form-control\" aria-invalid=\"false\" name=\"textarea-467\"><\/textarea><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"formGroup\">\n\t\t<p><label>Provide details of the activity, the time spent, the assistance required, from whom and when (including vouchers)<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"textarea-915\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea form-control\" aria-invalid=\"false\" name=\"textarea-915\"><\/textarea><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<h3>Sex and Intimacy\n\t<\/h3>\n\t<div class=\"formGroup\">\n\t\t<p><label>Outline how you want to engage in this activity<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"textarea-858\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea form-control\" aria-invalid=\"false\" name=\"textarea-858\"><\/textarea><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"formGroup\">\n\t\t<p><label>Provide details of the activity, the time spent, the assistance required, from whom and when (including vouchers)<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"textarea-873\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea form-control\" aria-invalid=\"false\" name=\"textarea-873\"><\/textarea><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<h3>Other Activities\n\t<\/h3>\n\t<div class=\"formGroup\">\n\t\t<p><label>Outline how you want to engage in this activity<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"textarea-224\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea form-control\" aria-invalid=\"false\" name=\"textarea-224\"><\/textarea><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"formGroup\">\n\t\t<p><label>Provide details of the activity, the time spent, the assistance required, from whom and when (including vouchers)<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"textarea-413\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea form-control\" aria-invalid=\"false\" name=\"textarea-413\"><\/textarea><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<h3>Behavioral Requirements\n\t<\/h3>\n\t<div class=\"formGroup\">\n\t\t<p><label>Communication<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"radio-641\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"radio-641\" value=\"Please select\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">Please select<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"radio\" name=\"radio-641\" value=\"No assistance required (including independent use of aids and adaptive technology)\" \/><span class=\"wpcf7-list-item-label\">No assistance required (including independent use of aids and adaptive technology)<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"radio\" name=\"radio-641\" value=\"Some 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aria-hidden=\"true\"><\/div>\n<\/form>\n<\/div>\n<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t","protected":false},"excerpt":{"rendered":"","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":""},"class_list":["post-12","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/disabilityservices247.com.au\/disabilityServiceForms\/wp-json\/wp\/v2\/pages\/12","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/disabilityservices247.com.au\/disabilityServiceForms\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/disabilityservices247.com.au\/disabilityServiceForms\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/disabilityservices247.com.au\/disabilityServiceForms\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/disabilityservices247.com.au\/disabilityServiceForms\/wp-json\/wp\/v2\/comments?post=12"}],"version-history":[{"count":20,"href":"https:\/\/disabilityservices247.com.au\/disabilityServiceForms\/wp-json\/wp\/v2\/pages\/12\/revisions"}],"predecessor-version":[{"id":53,"href":"https:\/\/disabilityservices247.com.au\/disabilityServiceForms\/wp-json\/wp\/v2\/pages\/12\/revisions\/53"}],"wp:attachment":[{"href":"https:\/\/disabilityservices247.com.au\/disabilityServiceForms\/wp-json\/wp\/v2\/media?parent=12"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}