About you

To complete this form you must be 18 years or older and be requesting services for yourself.

Fields marked with * are mandatory

Are you currently receiving services from Vision Australia?

Yes, I am an existing clientNo or I'm unsure

Your details

Step 1 of 3

Step 1 of 1

Fields marked with * are mandatory

So that we can match your details to our records, please complete the following information.

First name

Maximum 32 characters

Last name

Maximum 32 characters

Date of birth (DD/MM/YYYY)

If you are under 18, a parent or guardian must complete a Request services for my child form on your behalf.

Postcode

Maximum 4 characters

Phone

Enter 10 digits without spaces starting with ‘0’ for mobile or phone with area code

Email

If you do not have an email address, enter the email of a family member or carer, or call us on 1300 84 74 66.

Your needs

What has prompted you to seek services from us?

Is there anything you would like to tell us about your service request or needs?

By submitting this form, you confirm that you agree to the storing and processing of your personal data by Vision Australia as described in our Privacy Policy. The information you have submitted will be used to provide you with the most relevant content on Vision Australia services, news & events, and other opportunities for support

Contact preferences

Do you require an interpreter?

Yes, for languages other than EnglishNo, I do not require an interpreter

Select your preferred language

Funding status

Step 3 of 3

Fields marked with * are mandatory

If you are eligible for a funding source or government support (such as NDIS or My Aged Care) you need to access it to receive services from us. Alternatively, you can choose to speak to us about other options to access services.

Are you connected to a funding source or government support?

Yes, I have fundingNo, I do not have fundingI'm not sure

Which organisation provides the majority of your funding?

My Aged Care, Home Care Package or I live in residential aged careNDIS (National Disability Insurance Scheme)DVA (Department of Veteran Affairs)Other

Enter details on who provides your funding

Your needs

Is there anything you would like to tell us about your service request or needs?

By submitting this form, you confirm that you agree to the storing and processing of your personal data by Vision Australia as described in our Privacy Policy. The information you have submitted will be used to provide you with the most relevant content on Vision Australia services, news & events, and other opportunities for support

About you

Your details

Your needs

Contact preferences

Your vision

Funding status

Your needs