SPARK

  • Application Form SPARK Telethon Program

  • Welcome to the Application for the SPARK Telethon Program, proudly developed and facilitated by ADHD WA with the generous support of the Telethon 7.

    This is an initial step in the application process, and it typically takes approximately 20 minutes to complete.

    SPARK Telethon Key Subsidy Criteria

    1. Waiting time for assessment, treatment or support exceeds 5 months.
    2. Child is homeschooled or at risk of disengagement from formal education.
    3. Other family members in the household with ADHD (diagnosed or undiagnosed)
    4. Annual family income below 55K (individual) or 130K (combined family income)

    We deeply appreciate your interest in the SPARK Telethon Program and look forward to the opportunity to support you and your family on this journey.

    Thank you!

    Contact Us:
    📧 SPARK@adhdwa.org
    ☎️ (08) 6255 8880

    When you submit this form, it will not automatically collect your details like name and email address unless you provide it yourself.

  • Are you a *

  • Link to the Privacy Statement

  • By completing this form, I understand that:*
  • By completing this form, I confirm that the parents/carers are aware of the following:*

  • Personal Details

    Child's/adolescent's details
  • Date of birth*
     - -
  • Gender*
  • Preferred pronouns*
  • Is the child or adolescent of Aboriginal or Torres Strait Islander origin?*
  • Is the child/adolescent aware of the referral*

  • Next of Kin Details

  • Consent

    You have the option to withdraw your consent at any time by informing ADHD WA via email SPARK@adhdwa.org.
  • Parent/guardian consents to referral*
  • Are both parents/carers aware of and consent to the child/adolescent attending the Spark Telethon workshops?*
  • Consent to receive SMS, emails, or phone calls regarding the SPARK Telethon Program, including a follow up email 3 months after the workshop.*
  • Preferred method of communication*
  • Collection of deidentified data for research purposes.*

  • Demographics

  • Child/adolescent lives with*
  • How many siblings does the child/adolescent have? *
  • Number of persons in the household*
  • Accommodation type*
  • Annual household income*

  • Education

  • Is the child/adolescent*

  • Legal Matters

  • Has the child/adolescent been involved with the justice system (court orders, legal issues, etc.)?*
  • Is the child/adolescent under child protection services (case management, legal intervention, etc.)

  • Health and Wellbeing

  • ADHD presentations
  • Does the child/adolescent have a formal ADHD diagnosis?*
  • Is the child/adolescent accessing allied health services?*
  • Is the child/adolescent on medication for ADHD*
  • Has the child/adolescent experienced significant public health system wait periods for diagnosis, treatment, or support?*
  • Time waiting*
  • Do any biological family member exhibit symptoms or have a history of ADHD, whether suspected or formally diagnosed?*

  • Risk Factors

    Is the child/adolescent at risk?
  • Have you observed risk to self?*
  • Is the risk*
  • Have you observed risk to others?*
  • Is the risk*
  • Have you observed risk from others?*
  • Is the risk*
  • Is there a safety plan in place?*

  • Accessibility and Engagement

  • Rows
  • Are there any sensory sensitivities we should consider, such as sensitivity to bright lights, loud noises, or strong scents, etc?*
  • Are there any specific accessibility needs that we should be aware of?*
  • Is there anything else the facilitators need to be aware of to ensure that participation in the workshop is comfortable and inclusive?*
  • Should be Empty: