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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

Medical Diagnosis / Reports

Upload medical reports, assessments, or referral letters (max 10MB per file)

Additional Information

How did you hear about us?

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