Autism SA School Readiness Group Registration of Interest

Client Information

Client First Name *

Client Last Name *

Funding stream *

NDISFee for Service (out of pocket)

Diagnosis and/or medical conditions (please detail):

Parent/Caregiver Details

Parent/Caregiver First Name *

Parent/Caregiver Last Name *

Relationship to Client *

Email Address

Phone Number *

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 events Unsure

Additional information

How does your child like to play? *

Prefers to only play alone and doesn’t like others joining their play Can be protective of their play themes and toys Likes to play alongside adults only Likes to play alongside a peer Likes to play with adults Likes to play with one other child Thinks of their own play ideas and is able to engage other children in their play theme Likes 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 lead Prefers to have long turns in play or conversation Is not interested in other children’s turns in play Is able to understand and respect other’s turns in play and play ideas Enjoys socialising when others follow their lead A lot of structured support is required from an adult to socialise with and be understood by peers

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): *

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 them Enjoys making noise or sounds Becomes upset or appears uncomfortable (e.g., covering or closing eyes) when there is a lot of movement around them, bright colours, and/or light Is bothered by touch from other people, objects, or textures Enjoys touching items, people and/or engaging in messy play Enjoys and seeks out opportunities to engage in movement activities Seeks 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 overwhelmed Is able to regulate in a group with peers with adult support Benefits from 1:1 adult support to move away (i.e., into another room) to regulate Requires long periods of time (i.e., 30 minutes – 1 hour) to regulate themselves

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 planned Is 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 feelings Requires long periods of time (i.e., 30 minutes – 1 hour) to regulate themselves

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 bubbles Being 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 support Transitions between activities with minimal support when provided with structure, routine, and predictability Benefits from more time and support from an adult to transition to a new or different activity Consistently benefits from 1:1 adult support to transition to new or different activities Other

If 'other', please specify:

How does structure support your child? *

My child benefits from highly structured, familiar, and predictable activities and routines My child benefits from structured routines and activities but tolerates periods of change My child tolerates flexible structure in activities and routines throughout their day My child demonstrates a preference for participating in activities of their choice and may not follow a structured routine Other

If 'other', please specify:

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 floor Other (please specify)No support is required

If 'other', please specify:

My child requires support with: *

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

If 'other', please specify:

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.

Browse

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 family In most situations when dysregulated or stressed In day-to-day situations even when not during times of stress (e.g., to communicate their wants or needs) Less than once a month

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:

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

12. Registration Preferences

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.