Step 1 of 2 50% Thank you for registering your child to attend our group therapy classes. Our groups run for various sessions and the prices differ. Please make sure that you have checked with the clinic about the number of sessions and prices. The clinic can also give you information about the number of people attending each group, the clinicians and facilitators, the age of the children in the group. Here is some general information that applies to all our groups which we would like you to please read carefully before submitting this form. By submitting this form, you have agreed to the below terms and conditions. Please note that several people are attending groups and as such the groups are not fully confidential. While we ask everyone to treat the information about others with respect and to keep it confidential, we cannot guarantee this. There might be children from your child’s school or neighbourhood in the class. If you feel that any information needs to be kept confidential, please ask your child not to share it in the group. We will discuss confidentiality with everyone at the beginning of each group. Please note that full payment is collected before group commencement and these fees are non-refundable. It is expected that the participant attends all sessions as make up sessions are not available. If you miss a session, you can just continue to come to the future sessions. Your clinician can update you about any missing information, in the session that you attend. Please click this box to acknowledge that* I have read and understood the conditions of service. Todays Date* Your Name* First Last Is your child a current client in our clinic?*NoYesChild Name* First Last Date of Birth* Child InformationAge*Gender*MaleFemaleSchool*Grade*Emergency Contact Name* First Last Emergency Contact Phone*Relationship to the young person*Young person's Medicare NumberMedicare Reference NumberMedicare Expire Date DD MM YYYY Please select last day of the month for you expire date, Example: 31/OCT/2021 Private Health FundYoung person's Address* Street Address City State Post Code Parent/Caregiver 1 InformationName* First Last Relationship to the young person*AgeAddress (if not the same as young person) Street Address City State Post Code Occupation*Contact Number*Email (if you wish to recevie correspondence via email) Every now and again, we email parents with information regarding our clinic or future workshops. Would you like to receive this type of emails?*YesNoParent/Caregiver 2 InformationName* First Last Relationship to the young person*Age*Address (if not the same as Parent/Caregiver 1) Street Address City State Post Code Occupation*Contact Number*Email (if you wish to recevie correspondence via email) Medicare InformationFor Medicare rebates, we need to have more details from the parent/carer, as the claimant. If you wish to claim through Medicare, please add your details below, otherwise you may wish to leave blank. Parent Claimant Full name First Last Parent Claimant date of birth Parent Claimant Medicare numberReference NumberExpiry date DD MM YYYY Workshop QuestionsWhat is your child good at?*Do they have any emotional or behavioural challenges?*How is their relationship to siblings and peers at school?*Has your child ever been diagnosed with a medical, behavioural, or mental health condition by a professional practitioner?*Medical HistoryDoes your child use any regular medication?*Has your child ever had major illnesses or hospitalization?*Please let us know of who lives at home and the child’s care arrangement, including parenting situation:*Are there any court orders in place? If yes please indicate:*Anything else you would like us to be aware of:*When you press submit, please wait for the green line that appears and indicates that "Your form is now submitted". Please don't close the page before you see the green line, or we might not receive your form. Thank you