Referral form - Community Support and Inclusion Groups

ALPHA

The Alpha Social Group is a supportive social activity group which gives participants the opportunity to increase their social engagement. The group meets at places around Adelaide to support community participation and involvement. The skills developed through attendance at this group are readily transferable to other areas of life, including home, work, and community settings. Autism SA’s Program Facilitators support participants to enhance their communication skills and to adapt to social situations in the community.

Explorers Group (Community based social events)

A life and social skill development group that promotes learning through fun and supported activities in a range of on-site and community-based activities. These activities provide a diverse range of exciting activities with opportunities for social skill development, community participation, and independent living skills. Everyday life skills such as shopping, food preparation, cooking, kitchen hygiene and money handling can all be developed in this fun, group environment which also gives participants opportunities to connect with peers and make new friends.

Please note: Completing this form is an expression of interest in a group and does not guarantee a position within the group.

I am interested in: *

ALPHA Social Group (18yrs +)Explorers (13-17yrs)

Participant first name *

Participant last name *

Gender *

Date of birth (dd/mm/yyyy) *

Suburb *

Post Code *

Phone number *

Email Address *

Caregiver name (if applicable)

Caregiver phone number (if applicable)

Caregiver email (if applicable)

Please select from the below *

I would like contact to discuss the program furtherI understand the program and related costs and do not require further information ( place me on the waitlist )

What is your preferred method of communication?

PhoneEmailSMSAny

Person completing this form ( if not the participant or caregiver)

Contact details

Relationship to the particpant

About the Participant

What is the participant's Diagnosis *

No DiagnosisAutism Spectrum DisorderPhysical DisabilityHearing/Vision impairment (please advise in comment box below)Seizure/Heart Condition (please advise in comment below)ADHDOther (please advise in comment box below)

Please advise the participants diagnosis *

How does the participant communicate? *

Does the participant frequently display any of the below behaviours? Please tick which are relevant. *

No behavioursSelf-harm or harm of others (Please specify)Other (please specify)

Other, please specify *

Does the participant have any specific interests that they enjoy? * *

YesNo

If yes (please describe interests below) * *

Does the participant have any allergies? * *

YesNo

If yes (please describe allergies below)

I confirm that the description of the group above match the participant's NDIS goals and what they would like to get out to the group * *

Is there any other information you would like us to know about the participant? *

Is there anything specific that you are hoping to achieve from the participant's involvement in this group? *

Registration

Program structure

Full 12 session program cost is based on the NDIS group rates and will vary depending on ratio support required.
Each session includes 3 hours face to face and 30 minutes non face to face support per week.
Each 12 week block includes a progress meeting to ensure the program is meeting the particpants NDIS Goals and NDIS report provided.
This is a Program of Support and therefore the short term cancellation policy does not apply for non attendance
A two week cancellation period will apply if you wish to cease services

Please indicate whether you will be funding the group by NDIS or Fee for Service (FFS) *

NDISFee For Service

The CSI Group Progams are funded by Core - Assistance with Social, Economic and Community Participation. Please tick the box to confirm you have the available funding for this program *

NDIS Plan number *

NDIS Plan Start Date *

NDIS Plan End date *

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

Is your Plan *

Self ManagedAgency ManagedPlan Managed

Plan Manager Name *

Plan Manager Email

Is this a PACE plan

YesNoUnsure

Photographic/Video Release Authority

I grant Autism SA, its representatives, employees and suppliers the right to take/use photographs/videos of myself and/or my child/children and my property during attendance at the above-identified eventfor use in marketing collateral such as annual reports, publicity materials, advertising, social media and web content.It can also include paragraphs.

Response *

Yes, I grant Autism SA the rights aboveNo, I do not grant Autism SA the rights above

I have adequate funding available under my Core Funding - Community Social and Economic Participation Budget, and this does not expire during the dates I wish to book *

Please Sign *

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