About you

To complete this form you must be 18 years or older and be requesting services for yourself.
Fields marked with *  are mandatory

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.

Maximum 32 characters

Maximum 32 characters

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

Maximum 4 characters

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

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.

We ask this question to provide culturally appropriate, prioritised access to programs and services, and to improve overall health outcomes.

Your 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



Your vision

Step 2 of 3
Fields marked with *  are mandatory




We keep this information confidential and use it to match you with the service team that is best suited to assist you.

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.



Your 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