Request for Services - Pre-School

Preschool/Kindy Request for Services - Capacity Building Program

To be eligible for services from Autism SA's Inclusion Program, this request should be submitted by a representative of the early childhood setting and children must be registered clients of Autism SA.

Program Description:

This support will be provided in line with the Department for Education's Children and Students with Disability (CSWD) program. Support within this model focuses on capacity-building centre staff to help provide better support for children in your centres, with the aim of working together to build successful support outcomes. Initial observations will inform us of the most appropriate strategies for the child and how to best upskill and build capacity for your staff involved in their day-to-day learning and support.

It would be beneficial for the staff most involved with the child to be available to collaborate with our Early Childhood - Autism Engagement Advisor during this block of support.

Name of Kindergarten/Childcare Centre *

Address

Suburb

Postcode

Staff Contact Name *

Staff Contact Number *

E-Mail Address

Director Name *

Child's Name *

Gender *

Date of Birth *

Does the child have a Autism Spectrum Disorder diagnosis *

This support is only available to children who have a diagnosis of Autism Spectrum Disorder. Please do not continue if you have selected no. If you require more information please contact Autism SA on 1300 288 476.

Parent/carer first and last name *

Parent/carer relationship to child *

Parent/carer email

Parent/carer phone number

When did the child start preschool (if applicable) *

Start Time *

Finish Time *

Please identify the areas of focus for Autism SA early childhood support: *

Supporting transitionsIdentifying the child's strengths and areas for supportIdentifying and supporting sensory preferencesParticipation during group timeSupporting behaviours of concern/safety within the education settingDevelopment of self-care skillsSupporting transition to schoolAttendance at NEP meetingOther

Is the child receiving support from other agencies? If so, please specify the details of support.

What current level of support does the child receive from DfE/Gowrie/other? (hours) *

If 'other', please specify.

Has the Parent/Guardian been informed of the Request for Service *

Consent to visit *

I give permission for staff from Autism SA to visit our site to support the above-mentioned child.I agree to provide a safe working space for Autism SA staff to work with the child.I agree to provide materials that may be required to work with this child.

Date *