Festive SPOT Group Service Agreement

Facilitated by a multidisciplinary team, including Speech Pathologists and Occupational Therapists, the Festive SPOT is a fun, themed, skill building group to support young people aged 5-12 years, to attend a social group focused on developing range of functional skills related to festive celebrations, such as Christmas. Individuals will be supported to develop their self-advocacy skills and understanding of their own strengths and support needs in relation to celebrations. The group will facilitate peer interactions through fun games and activities that will also target a range of skills such as language development, fine and gross motor skills. The group is delivered 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 to Thursday. The group will run from 10:30-12pm, including an additional 15 minutes of non-face to face time allocated for preparation and pack up.

At the end of the group, your child will take home personalised resources to support them during the festive season, such as visual schedules and social stories.

Where: Northern Hub – Autism SA – 1/57 Elizabeth Way, Elizabeth SA 5112

Dates: The group runs across three days, from Tuesday the 19th of December to Thursday the 21st of December

Time: 10:30am to 12:00pm

Cost: $1,018.45 (includes 15 minutes of non face to face admin time each day)

(Please note: Pricing is based on NDIS Price Guidelines and is subject to change as and when the NDIS change their pricing).

Participant first name *

Participant last name *

Participant birth date *

Participant Preferred Pronouns

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

Preferred Pronouns Comments

Parent/Caregiver first name *

Parent/Caregiver last name *

Email Address *

Phone number: *

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 system 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?

Participant Registration

Please complete and submit this form to register for the December 2023 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

Please list your Plan Manager's name and email *

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

*

NDIS number *

NDIS Plan Dates *

Please upload a copy of your NDIS plan

Browse

How much will it cost?

$339.48 per 1 hour & 30 minute group + 15 minutes preparation and administration time.

This totals $1,018.45 (includes 15 minutes of non face to face admin time each day) for the three days.

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/or that I have provided. I authorise Autism SA, its assigns and transferees to copyright, use and publish any and all images in pint and/or electronically at any time from now into the future. I agree that Autism SA may use such photographs with or without my and/or my child's/children's name and for any lawful purpose, including for example such purposes as marketing collateral, annual reports, publicity materials, illustration, 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 understood all of the above regarding photographic/video release authority *

YesNo

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.

*

I agree to the cost for the Festive SP/OT Program as outlined above.

*

Please sign *

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