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RAQ Forms

FRC Client Registration Form

Fields marked with an * are compulsory.

"*" indicates required fields

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Venue (Office Use Only)*

Name*

Given Name Family name

Date of birth*

DD slash MM slash YYYY

Is this your legal name?*

Yes

No

Address*

Street Address Address Line 2 City State / Province / Region Postcode Country

Phone*

Email*

Postal Address (If different to above)

Yes

Postal Address

Street Address Address Line 2 City State / Province / Region Post Code Country

Gender

Male

Female

Other term

Why are you seeking assistance?

Please tick all that apply

Age-appropriate development

Communication participation and networks

Educations and skills training

Employment

Family functioning

Financial resilience

Housing

Material wellbeing and basic necessities

Mental health, wellbeing and self care

Personal and family safety

Physical health

How did you hear about our service?

How may we use your contact details?

Please tick all that apply

OK to leave message

OK to ring work

OK to ring home

OK to ring Mobile

OK to SMS

OK to send mail

OK to email

OK to reveal agency contact / identify organisation

Do you identify as Aboriginal and Torres Strait Islander?

No

Yes

Do you identify as Aboriginal and Torres Strait Islander?

Aboriginal

Torres Strait Islander

Both Aboriginal and Torres Strait Islander

Do you identify with a culture other than Australian?

No

Yes

Which cultural / ethnic / ancestral group do you identify with?

What was your country of birth?

What is the main language spoken at home?

Do you need us to provide an Interpreter?

Yes

No

If born outside Australia, Date of first arrival in Australia?

DD slash MM slash YYYY

Migration visa category if applicable?

Family

Humanitarian

Skilled

Other

N/A

Visa category?

What best describes your household composition?

Do you have a Department of Veteran’s Affairs Card?

No

Yes

Do you have a Carer?

No

Yes

Do you identify as having a disability?

No

Yes

What kind of disability do you have?

Intellectual / learning

Physical / diverse

Mental Health / psychiatric

Sensory / speech

Other (Please describe)

Disability type?

Are you eligible for NDIS (National Disability Insurance Scheme)?

NDIS eligible

NDIS in-progress access request

NDIS ineligible/not applicable

What is your main source of income?

What is your approximate gross income?

Please enter a number greater than or equal to 0.

Income frequency

Weekly

Fortnightly

Monthly

Annually

What is your highest level of education?

What is your employment status?

Are you a Carer?

YES – if the person you care for is a

Frail older person (65 years and above / 50 years and above if Indigenous)
Person aged 65 or younger (or 50 years and younger if Indigenous) with moderate, severe or profound disability who is living at home

No

Yes

Do you identify as one of the following?

Intersex

Transgender

Gay

Lesbian

Bisexual

Prefer not to say

Other term

NO

Please tick all that apply

Can RAQ contact you on behalf of our funding provider to complete a satisfaction survey or participate in research?

No

Yes

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