Request for Services - School

Request for Services - School - Capacity Building Program

To be eligible for services from Autism SA's School Inclusion Program, students must be registered clients of Autism SA and have an eligible NCCD rating.

Program Description:

This support will be provided in line with the Department for Education's Children and Students with Disability (CSWD) program. Individual support within this model focuses on capacity-building school staff to help provide better support for students in your classrooms, with the aim of working together to build successful educational outcomes. Initial classroom observations will inform us of the most appropriate strategies for your students and how to best upskill and build capacity for your staff involved in their day-to-day learning and support. Group programs on offer include Transition to High School and Lego Group.

It would be beneficial for the staff most involved with your student to be available to collaborate with our Autism Engagement Advisor during this block of support.

Name of person completing form: *

E-Mail Address *

Name of Class Teacher *

Class Teachers E-Mail Address *

General Details

Does the student have a diagnosis of Autism Spectrum Disorder *

YesNo

This support is only available to students 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.

Student Name *

Gender *

Year Level *

Date of Birth *

ATSI (Aboriginal and Torres Strait Islander)

Is the student in a special class/school/unit?

Parent/carer first and last name *

Parent/carer relationship to student *

Parent/carer contact phone number

Parent/carer email *

The parent/carer of the student will be contacted to advise of this request for support.

Is this request part of a group request? *

YesNo

Which group are you interested in? *

Transition to High SchoolLego Group

Please list the names of the other children you are registering for this group (they will require their own form submitted). *

School Details

Name of School *

Suburb of School *

School Phone Number

School Start Time & School Finish Time

Break Start & Finish Times

If Part-Time attendance by student, please specify times

Is the student receiving support from other agencies? (Including through NDIS funding) If so, please specify the details of support.

Is the student aware of the diagnosis?

NCCD Level of Adjustment

What is the student's NCCD level of adjustment? (Please note that only students with substantial or extensive ratings are eligible for CSWD-funded support.) *

SubstantialExtensive

Additional Comments

Please tick up to two options from the list below as the focus for this capacity building support: *

Access to Curriculum / Environmental Accommodations / Visual SupportsEmotional Regulation Organisation and Planning Transitions

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

Has the Class Teacher been informed of the Request for Service *

By submitting this Request for Service, I am confirming acceptance of the following on behalf of the school and Principal:

Consent to visit *

I give permission for staff from Autism SA to visit our school to support the above-mentioned student.I agree to provide a safe working space for Autism SA staff to work with the student.I agree to provide materials that may be required to work with this student.I agree that a relevant staff member will be available to participate in this capacity building program

Date *