Group Programs

Group Program Expression of Interest

Child Details(Required)

Childs Full Name Date of Birth

Child's School Year(Required)

Group Program(Required)

Please select the group program you're interested in.

Is your child on any Medication?(Required)

Yes

Does your child have any allergies we should be aware of?(Required)

PARENT / CARER DETAILS

Parent/Carer 1 Details(Required)

Parent/Carer Full Name

Parent/Carer Phone Number(Required)

Parent/Carer Email Address(Required)

Parent/Carer 2 Details(Required)

Parent/Carer 2 Full Name

Parent/Carer Phone Number(Required)

Parent/Carer Email(Required)

Parent Status(Required)

Single

Defacto Relationship

Process of Separation / Separated

Divorced

Married

Who holds Parental Responsibility for this child?(Required)

Both Mother and Father hold Parental Responsibility

Mother holds 100% Legal Parental Responsibility

Father holds 100% Legal Parental Responsibility

Legal Agency holds Legal Parental Responsibility

Other

Are there any Court Orders in place?(Required)

Yes - Children Court Orders

Yes - Family Court Orders

Do both Parents/Carers Consent to child attending the group?(Required)

Yes

Tell us a bit about your child

Describe the challenges or difficulties your child or adolescent is currently experiencing.(Required)

Please provide details that can assist us in gaining a better understanding of the situation.

Does your child experience any notable behavioral or emotional challenges that may affect their participation in a group setting.(Required)

Please provide details that can assist us in understanding their situation or emotional challenges that may affect their participation in a group setting. that would help us create the best possible experience for your child.

Is there any additional information that you feel would be helpful for us to know in order to better support your child?(Required)

Please provide details.

Does your child have a diagnosis?(Required)

Please elaborate on any diagnosis.

What would you like to achieve or improve with your child attending this group?(Required)

We would like to know what you are hoping to achieve or improve for your child in attending this group so we can work together towards those goals.

FUNDING

Payment

Private Paying

Private Health Fund

Medicare Mental Health Treatment Plan

NDIS Self Managed

NDIS Plan Managed