Application for Services

The contents of this application form will be used only by Legacy Lifestyle Support staff. It will provide a guide for us to understand how we can begin working with you. If you have difficulty completing this form, please complete the HELP section at the bottom so our team can make contact with you to provide assistance.

Need Help?

If you are experiencing difficulty completing this form, please call 0434 059 589 or email the Managing Director directly at services@legacylifestylesupports.com.au.

Parent/Guardian Information (if under 18)

Emergency Contact Details

Payment Details

Details of person completing this form

Details of person completing this form IF not the person with a disability or the Plan Nominee.