Explained by Brain Registration form 2021

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Name* This field is required.
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Other
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Phone Number* This field is required.Mobile number including country code e.g., +61 0499567067
Area Code
Phone Number
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Do you identify as:* This field is required.
Aboriginal
Torres Strait Islander
Aboriginal and Torres Strait Islander
Other Indigenous
Not Indigenous
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I am attending this course because, I am a:Please note: Parents and carers will be given priority for attending this course. While professionals may enrol you may be allocated to a seperate drop-in discussion group. This will be advised.
Biological parent
Kinship carer
Foster carer
Respite carer
Adoptive parent
Extended family member or informal support
Professional who supports children or Families impacted by FASD i.e., youth worker, teacher, psychologist etc
None of the above
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If you are a professional, what is your profession?Please note: Parents and carers will be given priority for attending this course. While professionals may enrol you may be allocated to a seperate drop-in discussion group. This will be advised.
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If you are a parent, I am parenting:Members of the same household are welcome to watch the video sessions together :)
On my own
With a partner
Shared parenting
Not currently parenting
Other
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EmploymentI am currently:
Working full-time within the home
Working full-time outside the home
Working part-time
Working casually
Other
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The biggest challenges with parenting my child/children with FASD/suspected FASD are:
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The biggest strengths of my young person with FASD/suspected FASD are:
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Topics I would like to see included in the sessions are:
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Have you completed training in FASD before?* This field is required.
YESNO
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Have you read "Explained by Brain: The FASD Workbook for Parents, Carers and Educators?It's ok if you haven't but I suggest getting a copy before to starting the sessions :)
Yes
Not yet
Some of it!
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How many children under 18 years live in your household?
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How many children in your household have a confirmed diagnosis of FASD?
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How many children in your household have suspected FASD?
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Information Storage and Usage* This field is required.Do you agree for your personal information to be stored securely and used to contact you for the purposes of the training sessions and other administrative purposes?
YESNO
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Evaluation* This field is required.I give permission for my personal and other information to be collected, stored, de-identified and used in evaluations of the training
YESNO
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I give permission to be contacted about participating in future FASD related research?* This field is required.(You change change your mind about this later!)
YESNO
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I give permission to be contacted by Dr Vanessa Spiller and her team about other training & resources that become available?* This field is required.(You can change your mind about this later!)
YESNO
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I understand that all content in this course is for information purposes only. The information provided is not a substitute for, or intended to replace, independent, psychological, legal or medical advice. This includes the content of the video's, workbooks, activity sheets, resources and discussions. Participants must consider the need to obtain independent professional advice relevant to their own circumstances.* This field is required.
YESNO
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I agree that Dr Vanessa Spiller will not be held accountable or liable for any decisions made by participants or consequences resulting either directly or indirectly from the information offered in any of these services or resources.* This field is required.
YESNO
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I will follow the copyright rights of Dr Vanessa Spiller. Apart from any use as permitted under the Copyright Act 1968, no part of this training or materials may be reproduced, copied, scanned, stored in a retrieval system, recorded, or transmitted, in any form or by any means, except where permission has been provided.* This field is required.
YESNO
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I understand participating in group drop-in sessions is optional and if I choose to attend my identity may be be revealed to other group members. While confidentiality among attendees is strongly recommended, I understand that it cannot be guaranteed and I will only share information that I am comfortable and permitted to share. I understand that I do not have to share any information I do not wish to.* This field is required.
YESNO
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By signing the below I agree to all the described conditions:* This field is required.
Clear
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I wish to attend:* This field is required.
Everything - the Introductory Session and all 10 video sessions (including the optional drop-in sessions) - $369 (plus GST)
Introductory session (including the optional drop-in session) - $59.99 (plus GST)
1 session (including the optional drop-in session) - $34.99 (plus GST)
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If attending a single session please indicate which session you wish to attend:
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Payment* This field is required.Please ensure payments are finalised at lease one week prior to the commencement of the course. No refunds will be available once the course has commenced. Please make sure that you can attend the scheduled dates. You will have access to all video materials until the scheduled conclusion of the course. You may watch the video's as many times as you like during that time.
I will be paying for this course myself please send me a payment link
Someone else is paying for me, I will need an invoice to be issued
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Invoice DetailsIf someone else is paying for your course and you require an invoice please provide the necessary details below e.g., name, organisation, address etc. This invoice will be provided to you to provide to your organisation and won't be directly sent to the organisation unless you specifically request this.
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How did you hear about Explained By Brain Online FASD training?* This field is required.
Facebook
JumpStart Psychology website
My support agency
Word-of-mouth
Internet search
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