Early Childhood Support Request for Service

Autism SA’s highly skilled and friendly Early Childhood Practitioners provide support to families and early childhood educators for the development of preschool-aged children on the autism spectrum.

Our family-centred Early Childhood Practitioners use evidence-based strategies to work collaboratively with the team around your child, including family, early childhood educators, and other professionals. We work together to encourage everyday learning and foster new skills that can be used at home, childcare, preschool, playgroups and in the community.

If you require any support in completing this form, please contact us on 08 8379 6976.

REFERRAL INFORMATION

Name of person completing the referral form *

Relationship to client *

Referrer Address *

Best Contact Number *

Email address of referrer *

CLIENT INFORMATION

Client name *

Preferred Name & Pronoun (he/him, she/her, they/them)

Date of Birth *

Client address *

Diagnosis and/or medical conditions *

Does the client/care team require an interpreter? *

YesNo

If yes, what language? *

EARLY CHILDHOOD SUPPORT BOOKING PREFERENCES

Upon receipt of the completed referral form, unless we need to discuss any of your responses with you first, our Client Relationship Team will develop a Service Agreement for you based on the answers you provide. These are typically blocks of 12 hours. Please note that Early Childhood session times are booked in 1.5 hour sessions with a mixture of face-to-face and non face-to face components. The agreement will be sent for your approval, and once approved you will be ready to be offered a suitable vacancy when it arises.

Please provide the below information to assist us in creating your agreement.

Will you be using NDIS funding of paying Fee for Service (out of pocket)? *

NDISFee for Service

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

Please upload your NDIS plan and/ or goals here

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NDIS Number *

Plan Start Date *

Plan end date *

My Improved Daily Living budget is: *

Self-ManagedPlan-ManagedAgency-Managed

Plan Manager name *

Plan Manager email address *

Is this a PACE plan

YesNoUnsure

BLOCK OF SUPPORT

Please identify the amount of hours you could like in your block of support: *

12 hour24 hourOther

Specific hours required *

LOCATION:

Please select where the client will receive support: *

HomeChildcare or Kindy settingOnline (telehealth)Other

Specify home adress *

Childcare/Kindy name and address *

If other, please detail *

Time preferences (select all that apply) *

Any time Specific time/s

Please specify: