Register Interest

We’re excited you’re exploring Power Unleashed. This form helps us understand a little more about you or the person you’re referring, so we can make sure the program is the right fit.

It only takes a couple of minutes to complete, and there’s no commitment, just the first step in a conversation.

Your Contact Details

Name

First

Last

Please enter your full name

Phone

Best contact number for a follow-up call.

So we can get back to you.

Your relationship to the participant

Select an option to let us know how you’re connected to the participant.

Power about us

Participants Details

Participants Name

First

Last

Address (optional)

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

NDIS Number (optional)

Optional, but helpful if you have it handy

Diagnosis / Support Needs (optional)

Please include anything that is relevant

Support Goals & Interests

What are the participants main goals (optional)

E.g., building confidence, improving independence, getting job-ready, social connection, etc.

Tell us a bit about the participant (optional)

What do they enjoy? What’s worked or not worked in past programs? Any other info you think we should know.

Helpful Extras

Best Contact Time (optional)

What’s the best time of day to reach out to you

How did you hear about Power Unleashed (optional)

Once you’re ready, click below and we’ll be in touch shortly.