Group Enquiry Form
Please fill in this form to enquire about our group programs. The form should take about 5-10 minutes to complete.
Child's First Name
*
Child's Last Name
*
Child's Date Of Birth
*
-
Day
-
Month
Year
DOB
Child's Gender
*
Female
Male
Other
Parent/Carer First Name
*
Parent/Carer Last Name
*
Email Address
*
example@example.com
Phone Number
*
Postcode
*
Back
Next
Please describe your current concerns and what or who prompted you to reach out to us
*
Back
Next
Which group programs are you interested in attending?
School Holidays - Social Minecrafters Group Program
School Holidays - CHEFS Cooking Group Program
School Holidays - Happy Hands Therapy Group Program
School Holidays - Lego Based Therapy Group Program
School Holidays - D.A.N.C.E Social Group Program
School Holidays - STEM WhizKidz Social Group Program
School Holidays - S.P.A.R.K Group Program
School Holidays - C.R.A.F.T.S Social Group Program
Ready Set Work Group Program
Term Time - 7-9 year olds Social Group Program
Term Time - 9-12 year olds Social Group Program
Term Time - Teens Social Group Program
Term Time: School Starters Group Program
Literacy Therapy Group Program
Not sure at this stage
We are a
*
Returning Client
New Client - Attending therapy services elsewhere
New Client - NOT Attending any other therapy
Please provide details of your current therapy
*
Diagnoses
ADD (Attention Deficit Disorder)
ADHD (Attention Deficit Hyperactivity Disorder)
Anxiety Disorder or Mood Disorder
Autism Spectrum Disorder (ASD) Level 1
Autism Spectrum Disorder (ASD) Level 2
Autism Spectrum Disorder (ASD) Level 3
Autism Spectrum Disorder (ASD) Unknown Level
Cerebral Palsy
Cognitive Delay
Downs Syndrome
Emotional Disorder
Fragile X Syndrome
Global Developmental Delay
Hearing Impairment
Learning Disabilities
Sensory Processing Disorder
Specific Learning Disorder (e.g. dyslexia, dysgraphia)
Vision Impairment
Other Condition or Syndrome
Please provide information about your child's toileting needs
*
Please Select
My child is completely independent with toileting and does not require any assistance
My child may require some assistance with toileting
My child requires assistance with toileting
My child uses nappies or incontinence products
Please provide information about any behaviour concerns
*
Please Select
There have never been any concerns raised regarding my child's behaviour
My child has some challenges with regulation or behaviour
My child requires 1:1 support with regulation or behaviour
Please describe examples of how you think your child may present behaviourally or emotionally in the group setting
*
Please provide details if a support worker assists your child
Back
Next
If you would like to share any previous reports/documents with us at this stage please attach them here. This information is valuable in helping us to build a picture of your needs and to determine how our service can best support you at this stage.
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Back
Next
Funding
*
Private Payer (including Medicare and Private Health)
Applying for NDIS
NDIS Funded
Is there anything else you would like us to know?
How did you find out about us?
*
Google Search
Paediatrician / Medical Professional
Other Allied Health Professional
Teacher
Friend
In The Cove
Facebook / Instagram
Walked Past
Screening
Community Health
Previous Client
Other
Submit Group Enquiry Form
Should be Empty: