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NDIS
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Provider
Lifestart
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Expression of Interest for Secret Agent Society
Secret Agent Society
Expression of Interest
Expression of interest for Secret Agent Society
Child's name
*
Child's age
*
Under 6
7
8
9
10
11
12
13 or older
Child's disability (please tick all that apply)
Autism
ADHD
Anxiety
Developmental delay
Speech delay
Intellectual disability
My child has not been diagnosed with a disability
Other (please specify)
If other, please specify
Parent/carer name
*
Email address
*
Phone number
*
Availability: Please choose one of the options below
*
I am available for the next online program.
I am not available for this program but I would like to register my interest in future programs.
I am available for future sessions on:
Monday
Tuesday
Wednesday
Thursday
Friday
Add more details (optional)
I understand there is a cost to attend the group. I can use my child's NDIS plan to pay for it.
Yes, confirm
How did you hear about the program?
*
My keyworker at Lifestart
Email from Lifestart
Lifestart website
Social media
Word of mouth (please specify below)
If word of mouth, please specify:
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Next steps: Please choose one of the options below
*
I would like to book a free 20 minute consultation to help me decide if the program is right for me and my child.
I have all the information I need and am ready to sign up.
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Child's age
*
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Which of the following statements apply to your child? Please tick all that apply
Has a diagnosis of Autism
Has social communication difficulties
Wants to work on social skills goals
Is interested in participating in an online group with peers
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My child is available for sessions after school:
Monday
Tuesday
Wednesday
Thursday
Friday
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Add more details (optional)
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