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Expression of interest for Hanen More Than Words program
Hanen More Than Words Program
Expression of Interest
Expression of interest for Hanen More Than Words program
Child's name
*
Child's age
0-5 years
6+ years
Child's disability (please tick all that apply)
Developmental delay
Speech delay
Autism
Intellectual disability
My child has not been diagnosed with a disability
Other (please specify)
If other, please specify
Parent/carer name
*
Email
*
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 parent sessions on
Monday
Tuesday
Wednesday
Thursday
Friday
Add more details (optional)
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 know more about the program
I have all the information I need and am ready to sign up
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Child's age
*
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Does the child have a diagnosis of autism or other social communication difficulties?
*
Yes
No
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