Application for Early Childhood Intervention and Core Services

1
Caregiver Name* This field is required.Please enter the name of the person completing this form
First Name
Last Name
2
Relationship to the child* This field is required.
Mother
Father
Grandparent
Carer
Advocate
Local Coordinator
Other
3
Child's Full Name* This field is required.
First Name
Middle Name
Last Name
4
Child's Date of Birth* This field is required.
Date
Day
Month
Year
5
Gender/sex of child* This field is required.
Male
Female
Other
6
Child's Diagnosis
ASD
GDD
None, but I am concerned about his/her development
Other
7
Which government area are you located in?
Armadale
Bassandean
Bayswater
Belmont
Cambridge
Canning
Cockburn
Claremont
Cottesloe
East Fremantle
Fremantle
Gosnells
Joondalup
Kalamunda
Kwinana
Melville
Mosman Park
Mundaring
Nedlands
Peel
Peppermint Grove
Perth
Rockingham
Serpentine-Jarrahdale
South Perth
Stirling
Subiaco
Swan
Victoria Park
Vincent
Wanneroo
Regional
8
Address - primary residence* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
9
Postal AddressIf different from primary residence
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
10
Phone Number* This field is required.
11
Email address* This field is required.
12
Confirm email address* This field is required.
example@example.com
13
Preferred mode of contact* This field is required.How would you prefer we contact you?
Email
Phone call
Text message
By mail
14
How did you hear about us?* This field is required.
Current or past ISADD client
Internet
Local coordinator
Other
15
ISADD's mission is to empower the personal network of the child with the skills necessary to support the child in meeting his/her highest potential. Parent/caregiver participation is an expectation of our service. Participation will include implementation and involvement in the implementation of recommended strategies.* This field is required.Will you be willing and able to meet this requirement?
Yes
Maybe
No
16
ISADD also acknowledges the need for parents/caregivers of children with ASD (and other disabilities) to have access to good quality training, coaching, and personal support. ISADD has a number of options available for families to support them in developing the skills and resilience required of them.* This field is required.Would you (and other key caregivers) be interested in engaging with such supports as a component of your child's intervention services?
Yes
Maybe
No
17
If there is lack of involvement, ISADD reserves the right to reconsider the appropriateness of service.* This field is required.Do you understand this condition of our service?
Yes
Maybe
No
18
Funding Options* This field is required.
Privately
Privately - in the process of obtaining funding and will pay privately until funding comes through
National Disability Insurance scheme (NDIS) funding
No funding, do not wish to pay privately, want to be demonstrate expression of interest (EOI) but can only accept a place when funding comes through
19
NDIS* This field is required.If you intend to use NDIS funds, how is your plan managed?
Agency Managed
Self Managed
Nominee Managed
Plan Managed
Unsure - have not completed planning process yet
Unsure - funds managed differently throughout plan
20
Please indicate which services from the list below you may be interested in for your child? These ABA services may be provided as stand alone services whilst still waiting to access to other suitable services. Please select all that apply.
Food Selectivity Intervention - Increasing the foods your child eats and reducing mealtime behaviour
Independent Toileting Skills
Independent Sleeping Skills
Balance - Create balance between child and adult interactions. Developing communication, cooperation, toleration and play
Addressing severe behaviour of concern through intensive intervention
Intensive Early Intervention (ABA) for children aged 4 years and younger
Intensive Early Intervention (ABA) for school aged children 5 years and above
Functional living skills for life
Parent Coaching
Other
21
Intervention Package-Balance* This field is required.Are you interested in applying this intervention service package?
Yes
Maybe
No
22
Intervention Package-Early Childhood Services (0-4 years old)* This field is required.Are you interested in applying this intervention service package?
Yes
Maybe
No
23
Core School Age Services* This field is required.Are you interested in applying this intervention service package?
Yes
Maybe
No
24
Targeted Intervention For A Behaviour of Concern* This field is required.Are you interested in applying this intervention service package?
Yes
Maybe
No
25
Please attach any relevant documentation e.g. reports, which you feel may provide us with a better picture of the needs of your child and family.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
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Availability* This field is required.Please outline your availability for intervention sessions. Bear in mind that our offers for service are in part based on having a home-based intervention team available in your area, therefore, it is best to provide with as many times as possible to work with. Example: Mon-Fri (8am to 5pm) except Wednesdays. Please note weekend sessions are not available.
27
Does your child engage in behaviour which results in significant harm to self or others?* This field is required.
YESNO
28
Please describe the nature and severity of the behaviour:
29
How easy was it to navigate this application form?This is an optional question but your feedback is valued as we are constantly striving to make what is a complex and stressful process as straightforward possible. Thank you.
1
2
3
4
5
VERY DIFFICULT
NO PROBLEM
30
I have read and understood ISADD’s Privacy and Confidentiality information. I agree to the conditions provided by ISADD.* This field is required.
31
Thank you so much for completing our form for Early Childhood Intervention (ECI) or Core Services. Submitting this form confirms your expression of interest in services. We encourage families to enquire about other providers in your area. In the meantime, we have recorded your child's details and the intervention services you are interested in. ISADD Services Coordinator will call the moment services become available in your area.
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