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Indigo's AAC Hire Service - Referral Form

Complete this form to request a quote for a short term hire of AAC equipment.

Before you complete this form:


By completing this form: 
I (the client) understand Indigo will collect, store, use and disclose my personal information for the purpose of providing me a service.

I (the client) am aware that my details will be kept securely, and will only be shared with others for the purpose of delivering my service.

I (the client) understand that before discussing any of my personal information, Indigo will ensure that the person making contact is myself or an authorised person.


If you answer no to either of the above questions, this may prevent us from being able to assist you fully or provide you with the specialist service you are seeking from our organisation.

I understand that I can withdraw my consent at any time, however I understand that this could impact my service delivery.

Indigo's Privacy Policy

We are unable to provide you with this specialist service if we do not have your consent to continue. 

Please review the Privacy Policy information, you will then be offered the option to provide your consent and continue with this online AAC Hire Service Referral form.

Consent means giving permission for something to happen. It means you agree that someone can do something.

Indigo collects, holds, uses and discloses personal information for different reasons, including:

  • To identify consumers, carers and service users;
  • To communicate with our service users and stakeholders about our services;
  • To provide services to consumers, carers and service users
  • To evaluate and improve our services
  • To meet statistical and reporting requirements.

What information do we collect about you?
Indigo will only collect, hold, use and share personal information that is needed to delivering services.  Personal information usually includes details like your name, address and date of birth.  Indigo may ask to collect sensitive information like health information, or racial and ethnic origins.

Indigo will always ask before collecting your information. 
If you cannot physically or legally give consent, a responsible person (like a family member or guardian) may provide consent on your behalf. 

Consent can be withdrawn at anytime. 
We may need to stop services if you withdraw consent. 

How do we collect personal information?
As far as possible, Indigo will collect personal information from you directly via the phone, email, or in person.  
Where this would be unreasonable or impracticable, information may be collected from someone else.  
Personal information that is sensitive information can only be collected with your consent, unless collection is required or authorised by law.

Providing Indigo with personal information about someone else
If you are making an enquiry or referral on behalf of another person, then you should only do so if you have their consent to provide us with their personal information. 
Please share this Privacy Statement with the person concerned, before sharing their personal information.

How is personal information stored and secured?
Indigo holds your personal information in:

  • electronic databases
  • some paper files held in secure systems and locked premises

We take reasonable steps to:

  • Update your personal information to ensure that it is correct, complete, and (in the case of use and disclosure) relevant
  • Protect your personal information from misuse, interference, and loss and from unauthorised access, modification, or accidental disclosure
  • Where Indigo no longer requires any personal information that it holds about you, Indigo will take reasonable steps to securely destroy or de-identify your information.

Sharing your personal information
Indigo respects your privacy and we will take reasonable steps to keep your personal information strictly confidential.

People who work at Indigo will not share your personal information with someone else, including overseas people or organisations, without your consent.

How do I access and update my personal information?
If you wish to access your personal information or you believe the information Indigo has about you is not correct, not up-to-date, not complete, not relevant, or misleading, please contact us via one of the methods listed below.

Email: quality@indigosolutions.org.au

Mail: Quality and Risk Professional, Indigo, ‘The Niche’, Suite A, 11 Aberdare Road, Nedlands WA 6009

Telephone: (08) 9381 0603 

Fax: (08) 9381 0611

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Client Details

Contact's relationship to Client - Person to contact about this hire -

A copy of this form will be sent to this address when submitted

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How is the Capacity Building budget managed in your plan

Phone and/or email

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Health Professional & Collection Details

Please provide the details of the therapist helping with this hire (ensure you have consent to provide their information)

How will the device be collected

Street address only. (Will not be shipped to a PO Box)

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Accent vocab
Grid Pad Software
Liberator Rugged Language
TD i-13 software
TD Eye Mobile Mini + Surface software
TD PCEye 5 + Surface software
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Switch Options - if switches are unavailable we may get in contact to discuss alternatives
Keyguard Options
What iPad case do you need
What iPad Mini case do you need
Do you require Mounting
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Please select one option from the list of supports.

*DISCLAIMER* Support offered cannot replace the support of the client's regular therapist. 

I, or someone supporting the client
This form is ready to submit
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General Referral Form Required

Before completing the 'AAC Hire Service Form' you will need to submit a request for services to:

  • Determine what equipment you wish to hire
  • Request an Indigo therapist to write a funding application.

Follow this link to Indigo's General Request Form

Please Note: This referral will be valid for 6 months

Next Steps 

  • A copy of this form will be sent to Indigo and the contact email provided
  • A quote will be generated based on the information provided
  • If you would like to make a booking, sign and return the quote to us

As consent has not been given to your information being collected, stored, used and disclosed for the purpose of providing you with a service, Indigo is unable to process your referral at this time.

To discuss further please contact us on 08 9381 0600


You can navigate away from this page or use the Submit button without any personal information being recorded by this service.