Group Program Expression of Interest | My Site

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Group Program
Expression of Interest

Referrals are made below. On completion of this form you will be added to our waitlist. Our team will be in contact to discuss current and future availability.

Community Gardening Program (Swan View)

Game Masters

Game Masters (Online)

Senior Social Group

Other Group

Detailed Description of Groups Available Here

Child's Name

Child's DOB

Sex

Gender

Diagnosis (if relevant)

Access Requirements

Allergies

Medications

Person Making Referral Name

Relationship to Child

Email

Phone

Address

Preferred Contact Method

Phone Call

Email

Text Message

Preferred Contact Time

Morning

Afternoon

Evening

Funding *

NDIS - Self-Managed

NDIS - Plan-Manager

Private

Other

NDIS Number

Plan Manager

Are there any court orders or parenting arrangements we need to aware of? *

Yes

No

If yes, please provide any relevant details

What are your child's current interests and strengths?

What does your child hope to gain from the group?

Does your child require any support with communication?

Does your child require additional support to regulate their emotions (do they have a tendency to run, become anxious or aggressive)?

Anything else we should know?

Your Signature

Select a date

Balance to Bloom acknowledge the traditional custodians of the land we work on, the Whadjuk people of Noongar Boodjar. We pay respect to the wisdom of elders, children and families and thank the land we gather on that provides for all.

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