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Expression of Interest for participation in SpeakUP
Expression of Interest for participation in SpeakUP
Name of young person
*
First
Last
Date of birth
*
DD slash MM slash YYYY
Address
*
Street Address
City
State
Postcode
Phone
*
Gender
*
Female
Male
Other
Parent/Carer name
*
First
Last
Relationship to child
*
Mother
Father
Email
*
Name of mainstream school and year
*
Diagnosis
*
Do you have an NDIS plan?
*
Yes
No
In the process
Is an interpreter required?
*
Yes
No
Which language?
*
Is the young person of Aboriginal or Torres Strait Islander origin?
*
No
Yes, Aboriginal
Yes, Torres Strait Islander
Yes, both Aboriginal and Torres Strait Islander
Hidden
What communication needs do we need to be aware of? (E.g., AAC device, verbal)
As this is an online program, and to assist us with tailoring our approach, it would be helpful to be aware of your young person's communication needs. Do they use:
*
Two-way conversations?
Simple sentences?
Short phrases less than 4 words?
An AAC device to support communication? (If yes, please provide its name in the additional information box below)
Prefer to write in words
Prefer to use visuals
Is there any additional information you would like to share to assist us with rapport building in the first session?
Is the young person aware of the referral?
*
Yes
No
What do you hope to get out of participating in the SpeakUP program?
*
What days of the week and times is your young person available for online sessions?
*
How did you hear about this program?
*
Flyer
School
Lifestart website
Facebook
Instagram
Community organisation or other (please state)
Community organisation or other (please state)
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