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Registration Form

Step 1 of 6 - Client Information

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The client is the child or young person that is accessing supports
Given name*
Surname*
Date of birth*
DD slash MM slash YYYY
Gender*
Home address*
Country of birth*
Cultural background*
Is the client*
- Aboriginal
- Torres Strait Islander
- Neither
What is the main language used at home by the client?*
Does an interpreter make communication easier?*
- Yes
- No
If an interpreter is helpful, which language is preferred?*
Does the client have a formally diagnosed disability or condition?*
- Yes
- No
Please provide details*

Parent/Carer 1
Given name*
Surname*
Phone*
Email*
Relationship with the client*
Does this person live at the above address with the client?*
- Yes
- No
Address*
What is the main language used at home by the parent/carer?*
Does using an interpreter make communication easier?*
- Yes
- No
If an interpreter is helpful, which language is preferred?*
Parent/Carer 2
Given name
Surname
Phone
Email
Relationship with the client
Does this person live at the above address with the client?
- Yes
- No
Address
What is the main language used at home by the parent/carer?
Does using an interpreter make communication easier?
- Yes
- No
If an interpreter is helpful, which language is preferred?
Who is the best person to contact about supports for the client?
What is the best way to contact this person?
- Phone
- Email
- Post

Please indicate which services you are interested in
- Behaviour
- Speech
- OT
- Junior
- Psychology
- Counselling
- Plan Management

Does the client have an NDIS plan (including budget)?
- Yes
- No
What is your NDIS number?
What is the NDIS Plan date?
Does the client have Helping Children with Autism (HCWA) or Better Start funding?*
- Yes
- No
How did you hear about Behaviour+?
- Family or Friends
- Health professionals
- Online
- Other Parents
Would you like to receive updates on and upcoming events and workshops?
- Yes
- No

Support Requirements
Does the client require an assessment?*
- Yes
- No
Does the client require an ongoing therapy booking?*
- Yes
- No
What is the preferred location for therapy?
- Behaviour+ Clinic
- Day care or Preschool
- School - Prior approval from principal required
- Home
- Other
Please note, travel fees may apply for therapy sessions at locations other than Behaviour+ Clinics
What is the preferred location for therapy? - Other
Choose preferred clinic location*
- Inner West
- Western Office
You can view our locations here
When is the client available for therapy sessions?
Monday
- Morning
- Afternoon
- After School
  (3pm Onwards)
When is the client available for therapy sessions?
Tuesday
- Morning
- Afternoon
- After School
  (3pm Onwards)
When is the client available for therapy sessions?
Wednesday
- Morning
- Afternoon
- After School
  (3pm Onwards)
When is the client available for therapy sessions?
Thursday
- Morning
- Afternoon
- After School
  (3pm Onwards)
When is the client available for therapy sessions?
Friday
- Morning
- Afternoon
- After School
  (3pm Onwards)
Educational Placements

Please provide details about the client’s preschool, school or other educational arrangements
What type/s of educational placement/s does the client attend?*
Please provide details about the client’s preschool, school or other educational arrangements
- Day care or pre-school
- Primary School
- High School
- Early intervention classes (NSW Education)
- School for Specific Purpose (SSP)
- Other (Please Specify)
Other Educational Placement/s
Does the client attend a support class?*
- Yes
- No
Type of Support Class
Client support goals
Skill Development Goals*
Please indicate any areas where the client requires support.
- Accessing the community e.g. attending appointments, road safety, shopping centres
- Communication and language e.g. speech, conversation skills, augmentative and alternative communication(AAC)
- Daily living skills e.g. dressing, self-care, transitions, following routines
- Eating and feeding e.g. restricted diet, independent mealtimes
- Emotional regulation e.g. coping skills, managing anxiety, understanding emotions
- Fine motor skills e.g. handwriting, scissor skills, doing up buttons or zippers
- Gross motor skills e.g. balance, jumping, ball games
- Play skills e.g. playing alone, using toys appropriately, imagination
- School skills e.g. school readiness, classroom participation
- Sleep management e.g. co-sleeping, bedtime routine, remaining in bed
- Social skills e.g. eye contact, sharing and turn taking, joint play, bullying
- Toilet training e.g. night-time dryness, independent toileting
Behaviour Support Goals
- Not following instructions e.g. not listening, refusal to co-operate
- Tantrums (melt downs) e.g. crying, dropping to the floor, screaming
- Absconding e.g. abandoning activities, disappearing when out
- Repetitive behaviours (stimming) e.g. hand flapping, repetitive talk
- Restricted behaviours e.g. controlling behaviour, obsessive interests or play
- Socially inappropriate behaviour e.g. inappropriate touching, swearing
- Property destruction e.g. ripping, throwing, breaking
- Eating non-food items (PICA) e.g. play dough, leaves, paper
- Aggression e.g. hitting, biting, scratching, hair pulling
- Self-injurious behaviour (SIB) e.g. head banging, self-biting, picking
Support Goals with Behaviour+ (Up to 3)*
Please list the priorities you would like to focus on with Behaviour+
Additional Information
Would you like to share any other information with Behaviour+
E.g. intensive ABA with a junior therapist, request for a formal behaviour support plan, therapy goals are time sensitive, risk of exclusion from school etc.

Name of child*
Consent*
I agree.
I give consent for Behaviour+ to collect, store and maintain personal information about my child (as named above) in order to:
- Deliver services or supports to my child
- Report statistical information (if required)
I understand that I can withdraw this consent at any time. However, in this instance Behaviour+ may not be able to provide the same services or supports.
Date*
DD slash MM slash YYYY
Name of person giving consent*
Relationship to child

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