ATS Mainstream Intake Form

Mainstream Intake Form

Client Information

Child's First Name *

Last Name *

Date Of Birth *

Parent / Guardian Name *

Phone/Mobile Number *

Email Address *

Address: *

Street address *Street address line 2

City *

State *

Postcode *

Country

Country of Birth *

Is your child of Aboriginal or Torres Strait Islander origin?

YesNo

Cultural background & requirements:Do you follow a religion, have any cultural needs or beliefs that we need to be aware of

Emergency Contact Details:

Which supports are you interested in? *

Afterschool ProgramsAuslan lessons 1:1Group ProgramsSchool Holiday Programs

How will these services be funded? *

Self FundedNDIS Plan ManagedNDIS Self ManagedOther

Where should we send invoices? *

About your child

Does your child have a disability and/or medical condition? *

If yes, Please tell us the diagnosis and how their disability / condition affects their daily life

Please provide details of any medications that need to be administered by staff

Do your child have any allergies or specific dietary requirements?

Dairy Free Gluten Free (Coeliac)Gluten Free (Intolerance)Lactose Free NutVegetarianVeganOtherNo food allergies or intolerances

If you answered "other" what is it?

Does your child have Anaphylaxis, Asthma or Epilepsy?

Anaphylaxis AsthmaEpilepsy

Please upload all relevant Medical Condition plans, including Anaphylaxis, Asthma, Allergy, Mental Health Safety Plans

Browse

Note that if your child has any of the above conditions, you must provide us with a copy of your medical management plan

Communication and Sensory Preferences:Tell us how your child likes to communicate and anything we need to know about how they interact with the world

Does your child have a mental health condition?

YesNo

Does your child exhibit any behaviours of concern? *

YesNo

If yes, please provide details

Does your child have a Behaviour Support Plan?

Please upload all relevant Documentation including Behaviour/Risk Alerts

Browse

Likes:Tell us about your child's strengths and the things they enjoy

Dislikes:Tell us about the things your child doesn't like or wants to avoid

How does your child interact with animals?

Anything else you would like us to know about your child?

Please upload any other relevant documentation

Browse

Please wait, files are uploading..