Client Details:

First Name:

Last Name:

Birthday

Day

Month

Year

Parent / Carer Details:

First name

Last name

Phone

Email

Multi-line address

Country/Region

Address

City

Zip / Postal code

Additional Information:

What year will your child be starting school?

What school will your child be attending?

Would you like to:

Enrol in Prep Ready Term 3 at Northern GC

Enrol in Prep Ready Term 4 at Nerang (Southern GC)

Receive a phone call for more information.

Medical Information / Diagnosis:

Diagnosis (if relevant)

Is there anything special about your child’s needs that we can be aware of to help them thrive in our group?

Please note: the above points will not exclude your child from the group, but helps us to better prepare and support your child to succeed.

Speech Pathologist (Name and Company Name)

Occupational Therapist (Name and Company Name)

Funding Information:

Funding Source

NDIS Self-Managed

NDIS Plan Managed

Medicare

Private

Please note we do not offer an NDIS Agency Managed payment option.

NDIS Participants Only:

NDIS Number:

Plan Start Date:

Day

Month

Year

Plan End Date:

Day

Month

Year

Payer / Plan Manager

Support Coordinator Details (name, email and phone)

NDIS goals

Please upload only your NDIS goals. This helps us ensure our group aligns with your specified goals.

Additional Documentation:

File upload

Consent Acknowledgement:

By submitting this form, I consent to the collection, storage, and use of my personal information by Beelieve Paediatric Therapy Pty Ltd and Speech for Kids in accordance with their Privacy Policy. I understand that my details will be used solely for the purposes of providing services and communication related to my therapy and care needs.

PREP Ready Group Expression of Interest:

Client Details:

Parent / Carer Details:

Additional Information:

Medical Information / Diagnosis:

Funding Information:

NDIS Participants Only:

Additional Documentation:

Consent Acknowledgement: