Little Windmills Intake Assessment Form Page 2
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4Little Windmills Intake Assessment Form
Parent/Guardian 2 Details:
First Name
Surname
DOB
Relationship Status (please circle):
Married, De-facto, Single, Other (if other please explain):
Name of Partner(If in a relationship):
First name
Surname
DOB
Relationship To Child (Please circle):
Parent, Guardian, Foster Carer, Relative, Other (please Explain):
Street
Suburb/Town
Residential Address (Po Box not accepted):
State
Post Code
Street
Suburb/Town
Postal Address (please write ‘As above’ if it’s
the same as the residential address):
State
Post Code
Mobile Phone
Home Phone
Work Phone
Further Contact Information:
Email:
(only complete the relevant columns)
Parent/Guardian 1
Parent/Guardian 2
Joint
Number of Dependents under 18 years of
age:
Age of Dependents:
Is either parent/guardian currently receiving
Yes/No
Centrelink payments? (please circle):
If So: Payment Type:
Is either parent/guardian currently
Yes / No
employed?(please circle):
Is either parent self employed? (If so please
provide a short description of your business
and your role):
Current housing situation (please circle):
Rent, Mortgage, Own Home, Government Assisted Housing, Other:
Details of Request
Short description of assistance (travel,
accommodation for treatment) / equipment,
how the equipment will be used and any
other expectations from Little Windmills:
Total amount required for the
Expenses/Item/s requested
Attach quote (If Applicable)
Is there a preferred supplier
Yes / No
If ‘Yes’ preferred suppliers details
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Parent category: Business