Name of young person*

First Last

Date of birth*

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

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)

Expression of Interest for participation in SpeakUP