Register Your Interest - Client Enquiry

Welcome to Noah's Ark

Complete this form if you would like to receive one of our services. All information provided is held within our secure Client Management System and is used to support us to offer you appropriate services when they are available.
To help us get you the information you need, are you:

A family looking for support for your childA professional seeking support for a child (with the family's permission to refer)An education setting (School, Kindergarten or Early Childhood Education Centre) seeking support for your studentsA professional looking for Learning & Development opportunities for yourselfA business seeking Learning & Development opportunities for your staff
Your information
Your Name*

First NameLast Name
Your Email*
example@example.com
Your Phone Number*
Format: 0000 000 000.
If you require an interpreter, please advise which language:
Professionals looking to refer a child

If you want to refer more than 1 child, please complete a form for each child.
Your organisation
The family are aware of this referral and have given permission for me to refer their child

YesNo
Parent/Carer/Guardian name*

First NameLast Name
I confirm that Parent/Carer/Guardian has the legal authority to make decisions on behalf of this child.*

Yes
Parent/Carer/Guardian Phone Number*
Please enter a valid phone number.Format: 0000 000 000.
Parent/Carer/Guardian email*
example@example.com
Families looking for support for your child

If you want to refer more than 1 child, please complete a form for each child.
Relationship to the child

MotherFatherCarer/GuardianOther
Child's name:*

First NameLast Name
Child's Date of Birth*

DayMonthYear
Date
Child's Gender*

MaleFemaleOther
Child's address*

Street Address

Street Address Line 2

CityState

Post Code
Is this child Aboriginal or Torres Strait Islander?

YesNoPrefer not to say
What is the main support you are looking for?

Speech PathologyOccupational TherapySpecialist EducatorPhysiotherapy
Are there other supports you might need?

Speech PathologyOccupational TherapySpecialist EducatorPhysiotherapyPsychologyGroup Programs for ChildrenWorkshops for familiesParent to Parent SupportOther
Would you be interested in Short-Term Telehealth support before an in person support is available?*

YesNo
Education settings (School, Kindergarden or Early Childhood Education Centre) seeking support for your students
Your School, Kindergarden or Early Childhood Education Centre
Address

Street Address

Street Address Line 2

CityState

Post Code
For professionals looking for Learning & Development opportunities
Select your Professional Background:

Speech PathologyOccupational TherapyPsychologyPhysiotherapySpecialist Teacher/EducatorSupport CoordinatorPrincipal/Centre DirectorOther
For businesses seeking Learning & Development opportunities for your staff
Your business name
Address

Street Address

Street Address Line 2

CityState

Post Code
Is there anything further you would like to share that would support our work together? For example - For families > your child's clinical needs and/or any diagnosis, or other important information about your child and family. For Education Settings > particular support you are seeking. For professionals > what learning you are keen to access.
How did you find out about us:*

NDIS directlyOther ProfessionalSchool, Kinder or ChildcareA community eventWord of mouthWebsiteFaceBookInstagramLinkedInLearning & Development BlogNoah's Ark NewsletterOther
Thank you for your interest in Noah’s Ark services. Our team will be in touch to talk with you about options.

By submitting this form, you agree to receive communications from Noah’s Ark. You can unsubscribe at any time.
Why We Collect Your Information
We collect this information to understand your needs and provide services that best support you. Your details will be stored securely in our client management system and handled in line with privacy and data protection requirements.
Date

DayMonthYear
Date
Client Enquiry Form - V1 July 2025
Should be Empty:

Welcome to Noah's Ark

Your information

Professionals looking to refer a child

Families looking for support for your child

Education settings (School, Kindergarden or Early Childhood Education Centre) seeking support for your students

For professionals looking for Learning & Development opportunities

For businesses seeking Learning & Development opportunities for your staff