LCQ Version

Which LCQ version you require a licence for? *

Living in the Community Questionnaire (LCQ)

Your details

First name *

Last name *

Organisation *

Email address *

Phone number *

Jurisdiction / service setting

Jurisdiction *

-- Please Select --New South WalesQueenslandSouth AustraliaTasmaniaVictoriaWestern AustraliaAustralia Capital TerritoryNorthern TerritoryOther

Other (please specify)

Service Setting *

-- Please Select --Public sectorCommunity Managed Organisation (COM/ NGO)Primary Health NetworkPrivate HospitalOther

Other (please specify)

Who will be offered the measure? *

• Children and Adolescents
• Adult
• Older Persons
• Not Applicable

Are you applying to use the LCQ/ LCQ-S *

-- Please Select --As an individual (for own interest or desktop review)On behalf of an organisation or service (for use in several units or distribution to clinicians to use as they choose)On behalf of a jurisdiction e.g. state or territory (for use in several services or across the whole jurisdiction)Other

Other (Please specify)

Terms and Condition

Terms and Conditions *

Please read the terms and conditions set out in the licence Agreement for the use of the Living in the Community Oquestionnaire.

• I accept the terms and conditions set out in the licence agreement

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