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info@beanstalkkids.com.au
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New client form
Date *
Child`s Name *
DOB *
Parent`s Name *
Parent`s Email *
Parent`s Contact Number *
Home Suburb *
Year Level *
Education / childcare setting: *
School / Childcare suburb: *
Why are you seeking our services?
Speech (increasing spoken language)
School support
Receptive communication (following instructions, understanding what others say)
Toilet training
Feeding (increasing variety and volume of food)
Behaviour support (reduce challenging behaviour or manage emotional regulation issues)
Teaching independence e.g. dressing, feeding self etc.
Social skills
EIBI (intensive ABA for 15-25 hours per week)
Anxiety
social skills (interacting with others)
Play skills (occupying their down time appropriately)
Specify school support:
Please specify
Within classroom to help stay on task
Social support in yard
Reduce challenging behaviour
Specify behaviour support:
Home
School
When in public
We´ll need you to take data on behaviour for the next weekor after a week (whichever comes sooner), see attached ABC behaviour diary where you´ll need to record what happened right before the challenging behaviour, what the behaviour was, and what happened / how you responded right after. This will give us an idea of how often it´s happening, as well as common triggers.If you´re wanting our help in multiple settings such as school and at home – please print two copies and write SCHOOL and HOME so we can tell what is happening in each setting. Please email this to
info@beanstalkkids.com.au
.Attach behaviour diary doc and behaviour support summary doc
You might be better served by an ACT practitioner, see
Russ Harris´ database
(be sure to look for someone who is a Registered Psychologist and has experience in the area you´re looking for help in) of people in Adelaide who might be able to help. Acceptance and Commitment Therapy is evidence based therapy proven to be effective for children and adults with anxiety.
What is the biggest priority out of the options you´ve chosen above?
Type of Education setting: *
Mainstream
Special Class
Special School
Do you have NDIS funding in place?
Yes
No
Where abouts in your funding cycle are you?
1st 3 Months
Middle of Plan
Near the end of Plan
Have you had your planning meeting yet?
Yes
No
You´ll want to book in for an initial assessment so that we can give you a report to take with you when you attend your planning meeting. See our
NDIS planning meeting tips
What other therapy is your child currently doing?
Speech
ABA
Occupational Therapy
Physiotherapy
Other
Please Specify?
Does your child have a diagnosis?
Yes
No
Please Select:
Autism Spectrum Disorder
Other
Please Specify!
Age at diagnosis
Other useful info: Is there anything else that´s useful to know like cultural considerations, parents are separated, family dynamics etc.?
How did you hear about us?
Another Beanstalk family
Google search
NDIS website
Plan manager / support coordinator
GP / Paediatrician
Speech Pathologist
Occupational Therapist
Facebook
Other
Please Specify!