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Freedom Social Skills - Intake Form
Please take the time to fill out this short form. Please note this information is confidential between you and the Directors of Freedom Social Skills Pty Ltd.
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How did you find out about our social groups?
*
Facebook
Google Search
Referral
Instagram
Flyer
Other:
Parents Full Name
*
Your answer
Email
*
Your answer
Contact Number
*
Your answer
Suburb
Your answer
Second Parent/Caregiver
Your answer
Email
Your answer
Contact Number
Your answer
Child's Full Name
*
Your answer
Child Date Of Birth
*
MM
/
DD
/
YYYY
Child's Gender
*
Female
Male
Other
Will you be using NDIS funding to pay for services?
*
Yes
No
Unsure
Please list any relevant diagnoses your child has been given.
Your answer
Please list the therapies your child is engaged with (e.g. Applied Behaviour Analysis/Behavioural Therapy, Psychologist, Speech Therapy, Occupational Therapy).
Your answer
Does your child have any allergies?
*
Yes
No
Required
If your child has allergies please list.
Your answer
Does your child require any medication which may need to be administered during a Social Skills session?
*
Yes
No
Required
Does your child have a form of medical condition that is deemed serious or potentially life threatening?
*
Yes
No
Required
If yes to the above, please provide details, or call admin to discuss further.
Your answer
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