Expression of Interest - Short Term Behaviour Management

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This form has been designed to help Super Kids to determine how our current Behaviour Management Services (including online courses, short term parent courses or Quick Consultation) could be designed and implemented for your child. It will help us select and offer the most appropriate service for you. It will also help to inform the clinician designing treatment by calling attention to personal and family values along with the practicality of these programs. This form is not a diagnostic tool.

Email *

Record my email address with my response

Parent or caregiver name(s)
*

Suburb
*

Child's name
*

Child's date of birth
*

YYYY

Child's diagnosis (if any)

Is your child an NDIS participant? *

Yes - Self managed

Yes - Plan managed

Yes - NDIA managed

No - I will be paying privately out of pocket

I don't know

I'd rather not say

How does your child communicate? (select all that apply)
*

Crying/tantrums/behaviours of concern

Pulling or hand leading

Gestures

Sounds or word approximations

Single words

Multiple words

AAC (eg: PECS, Proloquo2Go, Sign)

They have age appropriate speech and language development

Other:

Required

Why are you looking for behaviour management services, or what prompted you to seek services?

What are the top 1-3 goals you are hoping to achieve with behaviour management services? *

What is the main behaviour that you are concerned about? How often does this behaviour happen?

Is this behaviour dangerous (ie: cause injury to themselves or others, high risk of harm, or results in damages)?

Yes

Other:

If yes, please briefly describe the extent of injuries or damages and how often this happens.

Check the box that best describes typical challenging behaviour episodes for your child. (select all that apply)

Many mild to moderate behaviours that you're concerned about (e.g. whining, tantrums, refusal)

Engages in property damage

Engages in self-injury

Engages in aggression towards others

Requires physical restraints (e.g. confined to pram/stroller, needs to be held back by adult)

Requires environmental modifications (e.g. locked cupboards, gates)

Behaviours require peer or sibling removal for safety

Requires 1:1 adult support in any environment

Recent (last 30 days) injury to person, staff, peer as a result of behaviour

Does not tolerate giving up favourite items or activities

Engages in mild behaviour when told "no" or asked to wait (e.g. refusal, complaints, shouting)

Engages in moderate behaviour when told "no" or asked to wait (e.g. tantrums, crying)

Engages in mild behaviour when asked to do an adult led activity (e.g. refusal, complaints, shouting)

Engages in moderate behaviour when asked to do an adult led activity (e.g. tantrums, crying)

Engages in mild behaviour when asked to do a non-preferred task (e.g. refusal, complaints, shouting)

Engages in moderate behaviour when asked to do a non-preferred task (e.g. tantrums, crying)

Does not understand or follow instructions, but has no challenging behaviour

Has limited skills for their age, but has no challenging behaviour

Required

Where do the behaviours of concern occur? (check all that apply)

At home

At school/daycare

In the community (e.g. at the shops, the park, the beach)

Other:

What therapies, services or strategies have you already tried (if any), and how effective were they? *

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