Social Engagement Group - Elizabeth

Registration & Service Agreement

This group is a program for autistic children (5- 12 years old) with goals around social communication and regulation. The children in the group may be speaking or non-speaking and may have an AAC device to communicate. The group is delivered by Speech Pathologists and Occupational Therapists at a 1:1 ratio to ensure the individual’s communication and regulation needs are supported consistently throughout the group.

The group will run for 3 days from Tuesday 16th January to Thursday Thursday 18th January between 10:30-12:00pm, plus an additional 15 minutes of non-face to face time.

Location: Autism SA Northern Hub, Elizabeth (1/57 Elizabeth Way, Elizabeth)

Date: Tuesday 16th January 2024 to Thursday 18th January, 2024

Time: Sessions will be running between 10:30-12pm (face to face component)

Duration: 1 hr and 30 minute session and 15 mins non face to face over Tuesday to Thursday

Full Program Cost: $1018.45

Please note that the submission of this form does not guarantee entry into this group. The first 4 eligible participants to complete this form will secure places in the program and the remainder will be prioritised for last minute cancellations. Our team will be in touch with you in the coming weeks with more information to confirm these details.

Participant details

Participant first name *

Participant last name *

Parent/Caregiver first name *

Parent/Caregiver last name *

Participant birth date *

Email Address *

Phone number: *

Preferred Pronouns

He/Him/HisShe/Her/HersThey/Them/TheirsOther (please specify below)

Other, please specify below

About my child

What is your child's diagnosis? *

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

Please advise your child's diagnosis

How does your child communicate? *

Please advise what AAC device your child uses

Other, please specify

How does the individual engage in structured group games/play? *

Independently participates in all games (including movement games, question and answer games, role play etc)Engages in any game with support from an adult (e.g. to take turns, to follow instructions)Engages independently but only for preferred activities/activities of their own choiceRequires consistent support from an adult to participate in a group game (i.e. is unsure what to do, experiences challenges with allowing peers to lead)

Additional Comments

How does the individual manage being in a room with 3 others peers and 2 adults? *

Independently manages by acknowledging others personal space and boundaries and allowing others to be around themRequires support to understand others body language and how to respond (i.e. personal space)Able to manage being in the same room for short periods of time with adult support to access a break out room as requiredIs not currently able to be in a room with peers for longer than 5-10 minutes even with adult support

Additional Comments

How does the individual manage high levels of excitement or over-arousal? *

Independently regulates when excited or overwhelmedIs able to regulate in a group with peers with adult supportBenefits from 1:1 adult support to move away (i.e. into another room) to regulateRequires long periods of time (i.e. 30 minutes – 1 hour) to regulate themselves

Additional Comments

Does your child have any specific interests that they enjoy? *

YesNo

If yes (please describe interests 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 anything specific that you are hoping to achieve from your child’s involvement in this group?

Is there any other information you would like us to know about your child?

Registration/Service Agreement

Please complete and submit this form to register for the program. Once complete, your answers to the below questions will form your Service Agreement. You will be asked to agree to our Terms and Conditions and the costs of the program. You will receive a copy of your answers once submitted.

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

NDISFee For Service

I am *

Plan ManagedSelf ManagedAgency Managed

I give approval for a Service Booking to be made for the value of the program *

NDIS Number *

NDIS Plan Dates *

Plan Manager Name *

Plan Manager Email *

Please upload a copy of your NDIS plan

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How much will it cost?

Full program price is $1018.45.

Each session includes 1.5 hours face to face and 15 minutes non face to face support.

The cost of the program is in line with NDIS rates.

Please note if using NDIS funding, this will come from your Improved Daily Living Budget.

The relevant policies are:

T&C's Autism SA NDIS

T&C's Autism SA FFS

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 event for use in Autism SA marketing collateral such as annual reports, publicity materials, advertising, social media and web content.

Response *

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

I have read and accept the Terms and Conditions of this service, including the cancellation policy *

I have adequate funding available under my Improved Daily Living Budget, and this does not expire during the dates I wish to book *

Captcha *

Please sign *

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