Stepping Into Adulthood
Day Programme
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Parent / Carer Name
*
Parent / Carer Email Address
*
example@example.com
Parent / Carer Contact Phone Number
*
Parent / Carer Address
*
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Name of Child/Client
*
Child/ Client Date of Birth
*
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
1st Emergency Contact Name
*
1st Emergency Contact Phone Number
*
1st Emergency Contact Relationship to Child
*
Location you want to register for
Please Select
Christchurch
Wellington
What special interests does the child/client have?
Has your child/have you as the client, had a formal diagnosis? If Yes, please provide more info.
Describe your child's/you as the client, communication capability, i.e. non verbal, verbal with limited vocabulary, good communication
*
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Any specific environmental needs or triggers we should be aware of?
What are you/they specifically hoping to achieve or work on during the sessions?
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Payment terms (invoicing will be after each session, and payable within 7 days)
*
Invoicing (including individualised funding)
Carer Support (please contact emma@positivepathways.nz when invoice is sent)
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