Independent Living Centre Country Services Referral Form

TheIndependent Living Centre of Western Australia (ILC) provides information and advice to help people choose and access the most appropriate technology and equipment, to make living easier.

The ILC health professionals visit rural and remote locations in Western Australia, offering a range of services including:

-Individual appointments

-Information sessions to people with a disability, older people, families, carers, service providers, health professionals and educators

-Training and workshops

-Community display

-Videoconferencing, Skype and other video chat services

-Funding information

If you would like a visit from the ILC please complete this form and return to

ILC Country Services

Telephone: 9381 0600 / Fax:08 9381 0611 / Email:

Post:Independent Living Centre

Suite A, The Niche

11 Aberdare Road

Nedlands WA 6009

You will be contacted by an ILC staff member about the services we are able to offer you.

Client Name:

Date of Birth:

Aboriginal or Torres Strait Islander background Y/N:

Do you require interpreter? (If yes what language do you speak at home?)

Phone:

Address:

Diagnosis or impairment:

What types of equipment or services are you interested in exploring?

Communication systems

Computer and tablet use

Culturally appropriate aged care services

Environmental control equipment

Literacy and learning technology

Mobility equipment

Recreation equipment

Seating, positioning and transfer equipment

Self care and meal times equipment

Sexuality equipment

Telephone and emergency systems

Transport

Other (Please specify)

What is your goal?

What do you hope to achieve from the visit?

What equipment are you currently using or have previously used? Please describe your experience.

What barriers are affecting you achieving your goal?

(Consider physical, cognitive, sensory, communication, social skills, behaviour and environment)

What strengths and strategies are supporting you to work towards your goal?

(Consider physical, cognitive, sensory, communication, social skills, behaviour, environment, social networks)

Preferred appointment date and time:

Preferred appointment location:

Key Contact Name And Role:
Phone:
Email:

Family/Carers Name:

Phone:

Email:

Service Provider/School Name (if applicable):

Address:

Staff Name:
Phone:
Email:
Therapist(s) Name(if applicable):
Phone:
Email:

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