New Participant Enquiry Form
Email Address
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example@example.com
Child's Name
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Child's DOB
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Day
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Month
Year
Date
Child's Grade Level
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Parent / Carer's name
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Contact Number
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Your Suburb
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School / Kinder
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Which program/s are you interested in?
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Termly 8-week Program (currently on Tuesday and Thursday afternoons in Hampton)
School holidays program
School-based Program (please indicate your child's school or kinder on the next question)
Other
If you are interested in sessions held at your child's school or Kinder, please write the name of the school below
Do you have funding?
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NDIS (self managed)
NDIS (plan managed)
NDIS (NDIA managed) - please note we currently cannot take NDIA managed clients
Self-funded
Other
Does your child have an interest in Lego/Building activities?
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Yes - completes Lego/Duplo that are simple in design
Yes - completes Lego that is in the advertised range for their age
Yes - completes Lego that is above their advertised age
Not interested
Not sure
Other
What would you like your child to get out of an interest based construction group facilitated by a Speech Pathologist and Occupational Therapist?
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What are your child's interests (related to Lego or not, with specifics!) e.g. animals, Star Wars, Minecraft, houses and shops etc
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Please describe your child's strengths
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Please describe your child's difficulties and any diagnoses (to help us look at appropriate group formations and best supports/visuals we can provide)
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Has your child seen a Speech Pathologist before?
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No
Yes in the past
Yes currently
Has your child seen an Occupational Therapist before?
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No
Yes in the past
Yes currently
Do you have a recent (last 2 years) speech pathology and/or occupational therapy report you are able to provide?
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Yes
No
How does your child currently communicate? i.e. unclear single words only, long sentences but with some grammar mistakes or sequencing issues, non speaking but uses AAC etc.
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What sensory or emotional regulation supports / strategies are current in place to support your child?
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How does your child currently interact when in a group of peers?
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On which days/times are you and your child able to attend an initial assessment session? (Please tick all applicable so we can accommodate as soon as possible)
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Tuesday afternoon (Hampton)
Mondays (Parkdale)
Home visit during the week based on therapist availability (travel fee applies)
How did you hear about us?
*
Further comments or questions
Submit
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