Social Groups Booking Form

Please complete this form to register your interest in our Beyond Speech School Holidays Social Groups. Once this form is received, our Admin team will issue you an invoice. Your place in the group will be secured once payment is received. Please feel free to contact Admin. if you are unsure about any aspect of this form on admin@beyondspeech.com.au or 0417 035 016.

Your Full Name *

Your Child's Full Name *

Child's Date of Birth *

Child's Age *

Child's Gender *

Child's Grade/Year level *

Contact Number *

Address *

Town *

State *

Postcode *

Email *

Has your child accessed services with Beyond Speech over the past 12 months? *

YesNo

Is your child currently on the Beyond Speech waiting list? *

YesNo

Which Social Group would you like your child/teen to attend: *

Music - Tuesday April 9 to Thursday April 11 from 10am - 11.30amMinecraft - Grades 3-6 - Tuesday April 9 to Thursday April 11 from 9am - 10.30amMinecraft - Years 7-9 - Tuesday April 9 to Thursday April 11 from 11am - 12.30pmCooking and Craft - Grade 1 to 3 - Tuesday April 9 to Thursday April 11 from 1pm - 2.30pmCafe - Secondary Years 7 - 12 - Tuesday April 9 to Thursday April 11 from 10 - 11.30am

Please describe any challenges your child experiences that may impact their participation in the group (eg. emotional regulation difficulties, fine motor difficulties, hitting out when angry etc) *

What works best to support your child if they become distressed or dysregulated? (eg. going to a quiet space for a break, taking a short walk, using sensory toys, having a drink of water) *

Funding

How will you fund the group program: *

Private Paying with NDIS funds (Self-Managed)with NDIS funds (Plan-Managed)Other (Please specify below)

Other Funding

Plan Manager email:

You acknowledge that: *

Most sessions will be held at Healesville Primary School except for our Music Group and Cafe Group which will start at the Beyond Speech clinic.The Cafe group will involve walking to a local cafe. We encourage you to bring a support worker along to the group sessions if this may help you to stay safe, manage interactions and engage more effectively.Cafe group members will need to bring $20 to spend each day.Registration is subject to approval by clinical staff at Beyond Speech.Refunds are not available for cancellations or non-attendance to any session.Beyond Speech is not liable for any declined reimbursements from NDIS.

We will be in contact to supply you with an invoice. Your booking will be confirmed once payment has been received.

For any questions, please feel free to contact us on 0417 035 016 or at admin@beyondspeech.com.au

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