Stepping On - Online Referral

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Online Referral - Stepping On - Expression of Interest

Complete this form to register your interest in the Stepping On falls prevention program or to refer someone to the program. Activempowerment will contact the participant to discuss eligibility and available programs.

* Indicates required field

Who are you completing this form for? *

Participant Name *

First

Last

Email *

Phone Number *

Participant Suburb *

Preferred program location

Tick all that apply *

Bankstown Camden Campbelltown Fairfield Liverpool Unsure

Are you aged 65 years or older, or 45 years or older if you are Aboriginal or Torres Strait Islander?

Choose One *

Yes No

Are you aged 65 years or older, or 45 years or older if you are Aboriginal or Torres Strait Islander?

Are you able to walk safely around your home without using a walking frame?

Choose One *

Yes No

Are you able to walk safely around your home without using a walking frame?

Do you live in your own home or in the community rather than in a residential aged care home?

Choose One *

Yes No

Do you live in your own home or in the community rather than in a residential aged care home?

Are you able to participate in light exercise in a group setting?

Choose One *

Yes No

Are you able to participate in light exercise in a group setting?

Are you able to follow instructions and participate in group activities?

Choose One *

Yes No

Are you able to follow instructions and participate in group activities?

How did you hear about Stepping On? *

Referrer name and details *

Not required if you are referring yourself

Any other information?

(Please avoid including detailed medical information) *

Please avoid including detailed medical information

I confirm that I am the participant, or that the participant has consented to Activempowerment contacting them regarding the Stepping On program.

Choose One *

Yes No

Submit Referral

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Stepping On
- Stepping On - Online Referral