Outreach Program Initial Enquiry

1
Name of person completing this form* This field is required.
First Name
Last Name
2
Email* This field is required.
example@example.com
3
Please tick which best describes you below
I am a parent of a child or children with learning difficulties or other developmental delays
I am a teacher or representative from a school
I am an allied health professional (Psychologist, Occupational Therapist, Speech Pathologist)
I am a tutor or other professional working in the region
4
Which rural location are you interested in?* This field is required.
Wagga Wagga
Dubbo
Port Macquarie / Mid North Coast
5
Child's name* This field is required.
First Name
Last Name
6
Date of birth* This field is required.
Date
Year
Month
Day
7
School* This field is required.
8
Year Level in 2025* This field is required.
9
Child's postcode of main address
10
Parent/Carer Name* This field is required.
First Name
Last Name
11
Parent/Carer Name 2* This field is required.
First Name
Last Name
12
Contact Number* This field is required.
Area Code
Phone Number
13
Parent/Carer Email Address* This field is required.
example@example.com
14
Name* This field is required.
First Name
Last Name
15
Email* This field is required.
example@example.com
16
Please select the item below that best describes the legal parental and decision making responsibility for your child
Married with shared parental resposibility
Separated or divorced with shared parental responsibility
Single parent family with sole custody and parental responsibility (court orders may need to be provided)
Separated or divorced and no court orders are in place
Other / Please call me to discuss
17
Please tick all the areas of concern* This field is required.
Letter-sound knowledge
Spelling
Word reading / decoding
Reading fluency
Reading comprehension
Sentence or paragraph writing
Written expression (whole text)
Mathematics
Study skills
Motor skills
Speech and/or language
Attention and/or behaviour
Social skills
Other
18
Please select the services that you may be interested in for you or your child
Screening literacy assessment (Dyslexia and/or Dysgraphia screening)
Screening numeracy assessment (Dyscalculia screening)
General screening assessment (General screening for learning or other difficulties)
Diagnostic or comprehensive psychometric assessment (May be used to diagnose learning difficulties, ADHD or more generally, identify processing strengths and weaknesses)
Parent consultation to review previous information and provide a personalised plan
Intervention program for Reading, Writing or Mathematics
School or teacher consultation to provide guidance as to how to best support my child
Paediatrician consultation as part of ADHD assessment
Multidisciplinary ADHD assessment
19
Please select the services that you or your school may be interested in
Screening assessments for our students (Dyslexia, Dysgraphia, Dyscalculia, Autism, General processing and attention)
Individual case consultation to assist creating a plan or intervention program for one student
Diagnostic or comprehensive cognitive and psychometric assessments
General professional development or support in assisting children with learning difficulties
Development of individualised intervention programs
Supervision or professional development on assessment and intervention of learning difficulties
Should be Empty: