You can always press Enter⏎ to continue
Explained by Brain Registration form 2021
Please complete the following form. Be sure to answer every question!
30
Questions
START
1
Name
*
This field is required.
First Name
Last Name
Previous
Next
Submit
Press
Enter
2
Email
*
This field is required.
example@example.com
Previous
Next
Submit
Press
Enter
3
Address
*
This field is required.
Street Address
Street Address Line 2
City
State / Providence
Post Code / Zip Code
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Australia
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
Previous
Next
Submit
Press
Enter
4
Phone Number
*
This field is required.
Mobile number including country code e.g., +61 0499567067
Area Code
Phone Number
Previous
Next
Submit
Press
Enter
5
Do you identify as:
*
This field is required.
Aboriginal
Torres Strait Islander
Aboriginal and Torres Strait Islander
Other Indigenous
Not Indigenous
Aboriginal
Torres Strait Islander
Aboriginal and Torres Strait Islander
Other Indigenous
Not Indigenous
Previous
Next
Submit
Press
Enter
6
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
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
Previous
Next
Submit
Press
Enter
7
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.
Previous
Next
Submit
Press
Enter
8
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
On my own
With a partner
Shared parenting
Not currently parenting
Other
Previous
Next
Submit
Press
Enter
9
Employment
I am currently:
Working full-time within the home
Working full-time outside the home
Working part-time
Working casually
Other
Working full-time within the home
Working full-time outside the home
Working part-time
Working casually
Other
Previous
Next
Submit
Press
Enter
10
The biggest challenges with parenting my child/children with FASD/suspected FASD are:
Huge
Large
Normal
Small
Ok
quote
Created with Sketch.
Ok
Previous
Next
Submit
Press
Enter
11
The biggest strengths of my young person with FASD/suspected FASD are:
Huge
Large
Normal
Small
Ok
quote
Created with Sketch.
Ok
Previous
Next
Submit
Press
Enter
12
Topics I would like to see included in the sessions are:
Huge
Large
Normal
Small
Ok
quote
Created with Sketch.
Ok
Previous
Next
Submit
Press
Enter
13
Have you completed training in FASD before?
*
This field is required.
YES
NO
Previous
Next
Submit
Press
Enter
14
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!
Yes
Not yet
Some of it!
Previous
Next
Submit
Press
Enter
15
How many children under 18 years live in your household?
Previous
Next
Submit
Press
Enter
16
How many children in your household have a confirmed diagnosis of FASD?
Previous
Next
Submit
Press
Enter
17
How many children in your household have suspected FASD?
Previous
Next
Submit
Press
Enter
18
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?
YES
NO
Previous
Next
Submit
Press
Enter
19
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
YES
NO
Previous
Next
Submit
Press
Enter
20
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!)
YES
NO
Previous
Next
Submit
Press
Enter
21
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!)
YES
NO
Previous
Next
Submit
Press
Enter
22
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.
YES
NO
Previous
Next
Submit
Press
Enter
23
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.
YES
NO
Previous
Next
Submit
Press
Enter
24
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.
YES
NO
Previous
Next
Submit
Press
Enter
25
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.
YES
NO
Previous
Next
Submit
Press
Enter
26
By signing the below I agree to all the described conditions:
*
This field is required.
Clear
Previous
Next
Submit
Press
Enter
27
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)
Previous
Next
Submit
Press
Enter
28
If attending a single session please indicate which session you wish to attend:
Huge
Large
Normal
Small
Ok
quote
Created with Sketch.
Ok
Previous
Next
Submit
Press
Enter
29
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
Previous
Next
Submit
Press
Enter
30
Invoice Details
If 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.
Huge
Large
Normal
Small
Ok
quote
Created with Sketch.
Ok
Previous
Next
Submit
Press
Enter
31
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
Other
Facebook
JumpStart Psychology website
My support agency
Word-of-mouth
Internet search
Other
Previous
Next
Submit
Press
Enter
Should be Empty:
Question Label
1
of
31
See All
Go Back
Submit