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Name
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Do you have a disability?
No
Yes
What type of disability do you have?
Physical Disability (e.g. mobility issues, wheelchair user, limb loss)
Hearing Impairment / Deaf (e.g. partial or complete hearing loss)
Vision Impairment / Blind (e.g. low vision, total blindness)
Intellectual Disability (e.g. Down syndrome, developmental delays)
Psychosocial / Mental Health Disability (e.g. depression, schizophrenia, PTSD)
Cognitive / Neurological Disability (e.g. dementia, acquired brain injury, epilepsy)
Autism Spectrum Disorder (ASD) (including Asperger’s syndrome)
Learning Disability (e.g. dyslexia, dyscalculia)
Chronic Illness / Medical Condition (e.g. chronic pain, multiple sclerosis, diabetes — if it impacts daily life)
Speech or Communication Difficulty (e.g. non-verbal, speech impairment)
Other (please specify)
Are you currently receiving any government support?
No
Yes
What type of government support are you receiving?
NDIS
My Aged Care
Something else
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