SHFPACT Disability Services Enquiry Form

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Thank you for your interest in SHFPACT Disability Services. 

This form helps us understand your needs and identify the most suitable services. 

Your Details

Name(*)

Please type your full name.

Organisation (If applicable)

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Role (if applicable)

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Phone(*)

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Email(*)

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Select all that apply 

Preferred contact method

Preferred contact method

Email

Phone

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What Are You Enquiring About?

Select all that apply 

What are you enquiring about?

What are you enquiring about?

Individual Education

Individual Counselling

Group Education Program

SoSafe Training

Professional Learning or Staff Training

Parent/Carer Support

Consultation

Not sure / Other

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Who Is The Service For?

Complete the option that best matches your enquiry. 

A. Individual participant

Participant Name

Please type your full name.

Date of Birth

Please type your full name.

Preferred name and pronouns

Please type your full name.

Emergency contact for the participant

Please type your full name.

Your relationship to the participant

Please type your full name.

Is the participant aware of and supportive of this enquiry and the services being sought on their behalf?

Is the participant aware of and supportive of this enquiry and the services being sought on their behalf?

YesNoUnsure

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B. Education for a Participant Group

Please provide details about the organisation, setting, age range and number of participants.

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C. Training, SoSafe, parent/carer support or consultation  

Please provide details about the organisation, setting, number of attendees, and their roles.

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Tell Us About Your Enquiry  

What is the reason for your enquiry, and what would you like to achieve?

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Are there any support needs, concerns, or relevant background information we should be aware of to help us provide an appropriate service and facilitate participation?

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Funding

How do you expect this service to be funded?

How do you expect this service to be funded?

Self-funded

NDIS-funded

Scholarship requested

Organisation-funded

Unsure

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If NDIS funded, participant has funding in their Plan for Capacity Building Supports: 

Yes

No

Unsure

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How did you hear about us? 

How did you hear about us?

How did you hear about us?

Google or other online search

Professional or service referral

Family member, friend, or colleague

Community event (e.g. Disability Expo)

Social media

Previous use of SHFPACT services

Other

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Consent 

I confirm that the information provided is accurate to the best of my knowledge.

I understand that SHFPACT may contact me to discuss this enquiry and suitable next steps.

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(*)

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