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NDIS
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Provider
Lifestart
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EOI Secret Agent Society
Secret Agent Society
Expression of Interest
Child/young person details
First name
Last name
Date of birth
(Required)
DD slash MM slash YYYY
Child's disability (please tick all that apply)
(Required)
Autism level 1
Autism level 2
Autism level 3
ADHD
Anxiety
Developmental delay
Foetal Alcohol Syndrome
Intellectual disability
Speech delay
My child has not been diagnosed with a disability
Other (please specify)
Does your child have an NDIS plan?
(Required)
Yes
No
Other (please specify)
Is there a community activity that your child currently participates in, or is interested in participating in, where social skills can be practiced? E.g. sport, dance, Lego club, after school care, or interacting with peers outside of school? (please specify below)
Parent/carer details
First name
(Required)
Last name
(Required)
Phone
(Required)
Email
(Required)
Does the family speak a language other than English at home?
(Required)
Yes
No
Is an interpreter required for a phone conversation?
(Required)
Yes
No
Preferred language
Preferred method of contact
(Required)
Phone
Email
Preferred day or time for contact
(Required)
We will contact you to discuss the program. If you'd like, you can share any additional relevant information or specific questions you would like us to address.
How did you hear about the program?
My keyworker at Lifestart
Email from Lifestart
Lifestart website
Social media
Friend or family member
Community organisation (please specify below)
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