School Readiness Group Referral Form

Please complete this document when referring for the School Readiness Program, which runs from our Elizabeth clinic.

If you would like any assistance with completing this form, please contact our Client Relationship Team on 8379 6976.

Autism SA's School Readiness Program has two groups; Koala and Wallaby. Upon registering your interest, we will review the information you have provided and assign your child to the group that best suits their needs.

Koala Group:
With a maximum of four children supported by four adults, children are supported to feel secure, develop strategies for they can use when they feel uncomfortable, and explore routines similar to those in childcare, kindy, or school. Ideal for children who are learning to play with others, need lot of adult support to communicate, benefit from one-on-one co-regulation, and require consistent adult support for transitions or prefer their own routines.

The total price for this group is $5,189.23. This includes:

Goal Setting Session: At the start of the program, there will be a one-hour goal-setting session, which is charged at $193.99.
Program Sessions: The program includes 11 x 2-hour group-based sessions, charged at $436.48 per session.
Progress Report: A one-hour progress report, which is charged at $193.99.

Wallaby Group:

With a maximum of six children supported by three staff members, children participate in social and school-like activities, routines, and transitions. Ideal for children who enjoy playing with others, can communicate their needs, regulate with some adult support, and transition between activities with structure and predictability.

The total price for this group is $3,855.55. This includes:

Goal Setting Session: At the start of the program, there will be a one-hour goal-setting session, which is charged at $193.99.
Program Sessions: The program includes 11 x 3-hour group-based sessions, charged at $315.23 per session.
Progress Report: A one-hour progress report, which is charged at $193.99.

Client Information

Client First Name *

Client Last Name *

Date of Birth *

Funding stream *

NDISFee for Service (out of pocket)

If NDIS, how much funding are you able to allocate for this service?

NDIS Number *

Plan Start date *

Plan End date *

Plan Nominee (responsible person for making decisions about NDIS services on the behalf of the individual)

My Improved Daily Living (CB Daily Activities) budget is: *

Self-ManagedPlan-ManagedAgency-Managed

Plan Manager name *

Plan Manager email address *

Is this a PACE plan

YesNoUnsure

Please Upload your NDIS plan here

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Parent/Caregiver Details

Parent/Caregiver First Name *

Parent/Caregiver Last Name *

Relationship to Client *

Email Address

Phone Number *

About My Child

Diagnosis and/or medical conditions (please detail):

Does your child have any current care plans (such as Seizure, Asthma, Anaphylaxis) *

YesNo

If 'yes', which type of plan(s)

Do any of these plans require emergency medication administration (such as EpiPen, midazolam, Asthma Puffer)? *

YesNo

If 'yes', please specify *

Please upload relevant care plan/s

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Has your child received any therapy services previously? *

YesNo

If 'other', please specify:

Does your child attend any other group environment? Please select all that apply *

ChildcareKindergartenSchoolOther

If 'other', please specify:

1. Communication

How is your child currently communicating? *

Visuals or Augmentative and Alternative Communication (AAC) (e.g., visuals, communication book, speech output device).Non-speakingGestures (e.g., leading you by the hand)Echolalia (i.e., repetition of words, phrases, sentences your child has heard)Single words (e.g., help)Phrases (e.g., help me)Sentences (e.g., I need help)Conversations (i.e., back and forth talking about a topic with another person)

Additional information

If your child uses AAC, please detail which system they use:

What does your child communicate about? *

Wants and needsLikes and interestsPast eventsUnsure

Additional information

2. Social Play

How does your child like to play? *

Prefers to only play alone and doesn’t like others joining their playCan be protective of their play themes and toysLikes to play alongside adults onlyLikes to play alongside a peerLikes to play with adultsLikes to play with one other childThinks of their own play ideas and is able to engage other children in their play themeLikes to play with other children in a group

What type of play is your child interested in? *

Physical play (movement-based games)Constructive play (building and creating games)Sensory/cause and effect play (enjoying touching things, watching things move and fall)Social play (playing with others to achieve a common goal)Imaginative play (fantasy and make-believe games)Structured rule-based games (games like Simon says or Duck, duck goose)

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

Likes to take turns and share with others lots during play and follow other children’s leadPrefers to have long turns in play or conversationIs not interested in other children’s turns in playIs able to understand and respect other’s turns in play and play ideasEnjoys socialising when others follow their leadA lot of structured support is required from an adult to socialise with and be understood by peers

3. Toileting

Does your child need support with toileting? *

NoYes

Does your child have a continence care plan? *

NoYes

Please attach plan:

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What does your child currently wear? *

UnderwearPull ups/nappyOther

If 'other', please specify:

Please describe the type of support your child needs with toileting (e.g. reminders for when to go, support with wiping etc): *

4. Sensory

Does your child need support to regulate? *

YesNo

How does your child process sensory information? (select all that apply) *

Becomes upset or appears uncomfortable (e.g., covering ears) when there is noise around themEnjoys making noise or soundsBecomes upset or appears uncomfortable (e.g., covering or closing eyes) when there is a lot of movement around them, bright colours, and/or lightIs bothered by touch from other people, objects, or texturesEnjoys touching items, people and/or engaging in messy playEnjoys and seeks out opportunities to engage in movement activitiesSeeks opportunities to put food and/or objects in their mouthOther

How does your child manage high levels of excitement or over-arousal? *

Independently regulates when excited or overwhelmedIs able to regulate in a group with peers with adult supportBenefits from 1:1 adult support to move away (i.e., into another room) to regulateRequires long periods of time (i.e., 30 minutes – 1 hour) to regulate themselves

Additional Comments

How does your child manage when something unexpected happens or things don’t go as planned (i.e., run out of time for an activity or losing a game)?

Able to tolerate and doesn’t seem to be bothered when things are unexpected or don’t go as plannedIs disappointed but able to be supported through their feelings when things are unexpected or don’t go as planned Becomes overwhelmed and requires 1:1 adult support to manage their feelingsRequires long periods of time (i.e., 30 minutes – 1 hour) to regulate themselves

Additional Comments

If anything, what helps your child to regulate? (select all that apply)

Big, fast movements (i.e., running and crashing, etc)Breathing activities or blowing bubblesBeing alone in a separate space (i.e., a tent)Using visual toys (e.g., liquid timer or sensory light)Using ear defenders or headphones Having time with no demands placed on them (e.g., not being asked questions/to do things)Other

If 'other', please specify:

5. Structure and Transitions

How does your child transition in between tasks and activities? *

Transitions between activities by themselves or with minimal supportTransitions between activities with minimal support when provided with structure, routine, and predictabilityBenefits from more time and support from an adult to transition to a new or different activityConsistently benefits from 1:1 adult support to transition to new or different activitiesOther

If 'other', please specify:

How does structure support your child? *

My child benefits from highly structured, familiar, and predictable activities and routinesMy child benefits from structured routines and activities but tolerates periods of changeMy child tolerates flexible structure in activities and routines throughout their dayMy child demonstrates a preference for participating in activities of their choice and may not follow a structured routineOther

If 'other', please specify:

6. Gross motor

My child requires support with: *

Mobility skills (e.g., walking, running, jumping, hopping, climbing, balancing, etc.)Ball skills (e.g., throwing, catching, bouncing, etc.)Sitting upright on a chair or on the floorOther (please specify)No support is required

If 'other', please specify:

7. Fine motor

My child requires support with: *

Manipulating items with their hands (e.g., stacking blocks, attaching and detaching Lego, rolling playdough)HandwritingDrawingSelf-feeding (i.e., using their hands the eat and cutlery skills)Opening and closing containersDressing and fastener skills (e.g., buttons and zips)OtherNo support is required

If 'other', please specify:

8. Mealtime

Do you have any mealtime concerns for your child? *

NoYes

If 'yes', please specify:

Has your child previously had a mealtime assessment or mealtime therapy?

NoYes (please attach a copy of relevant reports)Currently on waitlist for mealtime assessment or therapy

Please attach mealtime reports:

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Does your child currently have an Oral Eating and Drinking Care Plan (OEDCP)?

NoYes

What level of support is required:

If yes, please attach copy of plan.

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9. Behaviour

Does your child frequently display any of the below? Select all that apply (Please note this is to allow us to best identify appropriate supports and allocate within the group) *

If 'other', please specify:

What situations does this happen? *

Only at home/with familyIn most situations when dysregulated or stressedIn day-to-day situations even when not during times of stress (e.g., to communicate their wants or needs)

10. Early Literacy Skills

My child requires support with: *

Syllables (e.g. cat = one syllable, hungry = two syllables)Rhyming (e.g. cat, hat, mat)Sound knowledge in words (e.g. shoe = /sh/ - /oo/)Engaging in shared reading (e.g. reading a book together)Develop their vocabularyReading simple wordsWriting their nameOtherNo support is required

If 'other', please specify:

11. Other

Please let us know if there are any other areas that you would like support for your child:

Booking Preferences

Verification *

Thank you for completing this referral form to support the appropriate allocation of your child in one of our School Readiness Groups. Please click submit.