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Application for Services

Please complete this application form to request services at Tshepong Centre. Our team will review your application and contact you within 5 business days.

Applicant Information

First Name *

Last Name *

Date of Birth *

ID Number *

Email *

Phone *

Physical Address

Guardian Information (if applicable)

Guardian Name

Relationship

Disability & Service Information

Type of Disability *

Services Requested *

Hold Ctrl (Windows) or Cmd (Mac) to select multiple services

Additional Information

Speech Therapy
Occupational Therapy
Physiotherapy
Equine Therapy
Skills Development
Daily Care
Computer Training
Literacy Development
Agriculture & Gardening
Independent Living Training