Referral & Registration Form Step 1 of 42 2% If you would like to register for one of our services, please complete the online form below. A member of our team will then be in touch with you to discuss the services you would like to access and their availability. If you have any questions around our current capacity, please feel free to call our office on 08 7085 3999. Disclaimer* By checking this box you acknowledge that I Can Jump Puddles collects the following information to assist in determining if we are able to provide you with the supports enquired. More details on how we store and what we do with your information can be found in our Privacy policy under the 'Resources' tab on our website. Services for RequestServices for Request* Support Coordination - CoS Specialised Support Coordination Developmental Education Positive Behaviour Support Early Childhood Intervention Occupational Therapist Speech Pathologist Physiotherapy Hydrotherapy Dietitian Social Work I Can Exercise Assistive Technology Consultation Functional Capacity Assessment Therapy Assistant Psychology Counselling Now and Next Preferred Days and TimesDo you have preferred days/times for support?* Yes No Preferred Days and Times* Monday - AM Monday - PM Tuesday - AM Tuesday - PM Wednesday - AM Wednesday - PM Thursday - AM Thursday - PM Friday - AM Friday - PM Are you a new or existing client with I Can Jump Puddles?* New Existing Are you an NDIS participant?*YesNo Funding Type* NDIS Private Medicare DCP Other DCP Office Address*Medicare Plan*Max. file size: 16 MB. Client DetailsSalutation* Mx Mrs Ms Mr Dr Prof. Birth Date*DayDay12345678910111213141516171819202122232425262728293031MonthMonth123456789101112YearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Name* First Last Preferred Name If preferred name is the same as the first name, please leave the preferred name blank Gender* Female Male Genderfluid Declined to Answer NDIS Number*Mobile Number*Phone NumberEmail Address* Preferred Communication Method* Phone Email Mail Residence Type* House Unit Apartment Home Address* Street Address Suburb State Postcode Use a different Mailing Address from above?* Yes No Mailing Address Street Address Suburb State Postcode Primary ContactIs this person a legal guardian of the client?*YesNoName* First Last Email* Phone*Relationship to Client* Medical DetailsDo you identify with a disability?YesNoHealthPrimary Disability*Please selectAcquired Brain InjuryADHDAdjustment DisorderAlcohol RelatedAlzheimers DiseaseAmputationAngelman SyndromeAnkylosing SpondylitisAnoxia/HypoxiaAntley-Baxler Fieffers SyndromeAnxietyAphrasiaArthrogryposisAsperger SyndromeAtaxiaAutismBack InjuryBeckwith-Wiedemann SyndromeBehavioural DisorderBi Polar affective DisorderBlindCerebellar DegenerationCerebral LeukodystrophyCerebral PalsyCervical SpondylitisCharcot-Marie-Tooth DiseaseChiari Type 1Chromosome DeletionConduct DisorderCongenital DeformityCri Du Chat SyndromeCVADeafDeafblind (dual disability)DementiaDepressionDevelopmental delayDevelopmental language disorderDiffused SclerodermaDiGeorge SyndromeDown SyndromeDravet SyndromeDysphasiaDyspraxiaDystoniaEating DisorderEmphysemaEpilepsyExpressive DisorderFamilial Spastic ParesisFibrodysplasia Ossificans Progressiva (FOP)FibromyalgiaFriedreichs AtaxiaFrontal Lobe DamageGlioblastomaGuillain Baree SyndromeGuillain Barre SyndromeHearingHepatoblastomaHereditary Spastic ParaparesisHigher Functioning AutismHIV - related Brain InjuryHomocystinuriaHuntingtons DiseaseHyperflexionHyperopia (Long Sighted)HypotoniaImpulse Control DisorderInfectionIntellectual DisabilityLanguage DisorderLennox-Gastaut SyndromeLower Limb ImpairmentMental HealthMild Hearing LossMixed Receptive/Exp DisorderModerate Hearing LossMoebious SyndromeMotor Neurone DiseaseMultiple SclerosisMulti System AtrophyMuscular AtrophyMuscular DystrophyMyasthenia GravisMyopia (Short Sighted)NeurofibromatosisNeurologicalNeuropathyNystagmusObsessive Compulsive DisorderOppositional Defiance DisorderOsteo ArthritisOsteogenesis ImperfectaOther Brain InjuryOther - GeneticOther NeurologicalOther NeurologicalOther PhysicalOther PsychiatricParkinsons DiseasePersonality DisorderPervasive Developmental DisorderPhysicalPolymyositisPost Polio SyndromePost Traumatic Stress DisorderPrader Willi SyndromeProfound Hearing LossPsychiatricPsychosocialRaynaud's PhenomenonReceptive Language DisorderRheumatoid ArthritisRussell Silver SyndromeScheuermanns DiseaseSchizophreniaScoliosisSemantic/Pragmatic DisorderSleep DisorderSmith-Magenis SyndromeSotos SyndromeSpecific Learning Disability / ADDSpeechSpeech and Language DelaySpina BifidaSpinal Cord InjurySpinal Cord StenosisSpinal Muscular AtrophySpinocerebellar DegenerationStrabismusSubstance AbuseSyringomyeliaTHI - AssaultTHI - Home/Recreation AccidentTHI - MVATHI - OtherTHI - PedestrianTHI - Work AccidentTourette'sTranslocated Chromosome 2 & 6TumourTurner's SyndromeVisionVision ImpairedVisionTHI - PedestrianWilliams SyndromeSecondary Disability*Please selectAcquired Brain InjuryADHDAdjustment DisorderAlcohol RelatedAlzheimers DiseaseAmputationAngelman SyndromeAnkylosing SpondylitisAnoxia/HypoxiaAntley-Baxler Fieffers SyndromeAnxietyAphrasiaArthrogryposisAsperger SyndromeAtaxiaAutismBack InjuryBeckwith-Wiedemann SyndromeBehavioural DisorderBi Polar affective DisorderBlindCerebellar DegenerationCerebral LeukodystrophyCerebral PalsyCervical SpondylitisCharcot-Marie-Tooth DiseaseChiari Type 1Chromosome DeletionConduct DisorderCongenital DeformityCri Du Chat SyndromeCVADeafDeafblind (dual disability)DementiaDepressionDevelopmental delayDevelopmental delay 0-5 yrs onlyDevelopmental language disorderDiffused SclerodermaDiGeorge SyndromeDown SyndromeDravet SyndromeDysphasiaDyspraxiaDystoniaEating DisorderEmphysemaEpilepsyExpressive DisorderFamilial Spastic ParesisFibrodysplasia Ossificans Progressiva (FOP)FibromyalgiaFriedreichs AtaxiaFrontal Lobe DamageGlioblastomaGuillain Baree SyndromeGuillain Barre SyndromeHearingHepatoblastomaHereditary Spastic ParaparesisHigher Functioning AutismHIV - related Brain InjuryHomocystinuriaHuntingtons DiseaseHyperflexionHyperopia (Long Sighted)HypotoniaImpulse Control DisorderInfectionIntellectual DisabilityIntellectual inc Down SyndromeLanguage DisorderLennox-Gastaut SyndromeLower Limb ImpairmentMental HealthMild Hearing LossMixed Receptive/Exp DisorderModerate Hearing LossMoebious SyndromeMotor Neurone DiseaseMultiple SclerosisMulti System AtrophyMuscular AtrophyMuscular DystrophyMyasthenia GravisMyopia (Short Sighted)NeurofibromatosisNeurologicalNeuropathyNystagmusObsessive Compulsive DisorderOppositional Defiance DisorderOsteo ArthritisOsteogenesis ImperfectaOther Brain InjuryOther - GeneticOther NeurologicalOther NeurologicalOther PhysicalOther PsychiatricParkinsons DiseasePersonality DisorderPervasive Developmental DisorderPhysicalPolymyositisPost Polio SyndromePost Traumatic Stress DisorderPrader Willi SyndromeProfound Hearing LossPsychiatricPsychosocialRaynaud's PhenomenonReceptive Language DisorderRheumatoid ArthritisRussell Silver SyndromeScheuermanns DiseaseSchizophreniaScoliosisSemantic/Pragmatic DisorderSleep DisorderSmith-Magenis SyndromeSotos SyndromeSpecific Learning Disability / ADDSpeechSpeech and Language DelaySpina BifidaSpinal Cord InjurySpinal Cord StenosisSpinal Muscular AtrophySpinocerebellar DegenerationStrabismusSubstance AbuseSyringomyeliaTHI - AssaultTHI - Home/Recreation AccidentTHI - MVATHI - OtherTHI - PedestrianTHI - Work AccidentTourette'sTranslocated Chromosome 2 & 6TumourTurner's SyndromeVisionVision- Home/Recreation AccidentVision ImpairedVisionTHI - PedestrianWilliams SyndromeAutism Level*123Other, please specify:Health ContinuedOther Medical/Health ConditionsMental Health ConditionsMedicationsVision*ExcellentGoodFairPoorVision LossAids Or Equipment Used / Other Information - VisionHearing*ExcellentGoodFairPoorHearing LossAids Or Equipment Used / Other Information - HearingCommunication*ExcellentGoodFairPoorAids Or Equipment Used / Other Information - CommunicationMobility*ExcellentGoodFairPoorAids Or Equipment Used / Other Information - MobilityMedical Reports, Medication Summaries You Would Like To Upload Drop files here or Select files Max. file size: 16 MB. Client DemographicsCountry of Birth*AustraliaAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland IslandsMain Language Spoken at Home*Do you require an interpreter?* Yes No Interpreter Details*Indigenous Status* Aboriginal but not Torres Strait Islander Origin Torres Strait Islander but not Aboriginal Origin Both Aboriginal and Torres Strait Islander Origin Neither Aboriginal nor Torres Strait Islander Origin Declined to Answer NDIS PlanStart Date* DD slash MM slash YYYY End Date* DD slash MM slash YYYY Funding Management* NDIA Managed Plan Managed Self-Managed Plan Management Company*Email address for invoices Please upload NDIS PlanMax. file size: 16 MB. SafetyAre There Any Smokers In The Household?* Yes No Is anyone at your/the clients property known to be aggressive or violent?* Yes No If yes, please describe*Does anyone at your/the clients property have a criminal history?* Yes No If yes, please describe*Is there a history of people using drugs or alcohol at the property?* Yes No If yes, please describe*Are you aware of any firearms or Weapons being stored at the property?* Yes No If yes, please describe*Do you have any pets at your premises?* Yes No If yes, please describe*Are there any other factors we should be aware of?* RiskAny risks/safety concerns we should be aware of? Client DetailsClient Full Name*NDIS Number* Support CoordinationSupports Required - Support Coordination* Housing Transitioning Out of School First NDIS Plan Justice Funding Allocated - Support CoordinationAdditional Comments - Support Coordination Specialist Support CoordinationSupports Required? (SSC)* First NDIS Plan Housing Justice Transitioning Out of Hospital Transitioning Out of School Funding Allocated (SSC)Additional Comments (SSC) Developmental EducationWhat are the participant’s goals for Developmental Education support?*Please Choose* Assessment Consult What support do you require? (tick box and comment box as needed) - Developmental Education* Independent Living Skills e.g. self-care, transport training, cooking, healthy choices, safety skills Relationship/ social skills Developing Routines Self-Regulation skills/ understanding emotions Building self-esteem Transition program e.g. to school Employment Adaptive Behaviour Assessment (e.g. Vineland, ABAS) Positive Behaviour Support Initial Assessment for recommendation report Road Safety Assessment Other Where is the preferred location of support? - Developmental Education* School Home Work How many hours of Developmental Education support required if known?Additional Comments - Developmental Education PhysiotherapyWhat are the participant’s goals for physiotherapy support?*What support do you require (Physio)? (tick box and comment box as needed)* Functional Capacity Assessment Access Request Equipment Mobility Cough Assist Falls Risk Assessment Transfer and Positioning Care Plan: any training required for care givers? Strength Program: In Home / In Gym Hydrotherapy Please Choose - Physiotherapy* Assessment Consult How many hours of physiotherapy support required if known?Additional Comments (Physio) PsychologyWhat is the preferred location of support?*HomeSchoolWorkOtherPlease Choose* Consultation Assessment What are the participant's goals for psychology support?*How many hours of support are required? (If known) DieteticsBrief overview of NDIS plan/ supports currently in place (any Dietetics input past or current)*What are the participant’s goals for Dietitian support?*Please Choose* Assessment Consult What support do you require? (Dietetics)* Goal specific strategies/ suggestions Burst of dietetic intervention Cooking classes in home / group Supermarket tour Meal planning Other Initial number of hours of dietetic support required if known?Preferred location of support? (Dietetics)* Home School Work Current dietary requirements?*Food Intolerances/ Allergies?*Food texture requirements e.g. normal, soft, puree*Additional enteral nutrition e.g. tube feeding or nutrition supplements? Provide brief overview of product/ volume per day:*Provide brief overview of product/volume per day*Independent with food preparation/feeding?* Yes No Support with food preparation? Who supports you with this if needed?*Possible underlying challenges involved?* Emotional regulation Sensory processing Cognition Social skills/ relationships Gross or fine motor skills Other Previous nutrition/ dietetic supports attempted to address this concern, Identified Concern, Strategies Tried, Outcome/ Effectiveness:*Identified concern*Strategies tried?*Outcome/effectiveness?* CounsellingWhat are the participant's goals for counselling support?*Support Required? (Counselling)* Relationship/ social skills development Anxiety and trauma support and management Family and carer support Managing transitions and adapting to changes Other Please Choose* Assessment Consult Where is the preferred location of support? (Counselling)* Home School Work How many hours of support are required if known? (Counselling)Additional Comments (Counselling) Occupational TherapyWhat are the participant’s goals for Occupational Therapy support?*What support do you require? (OT)* Independent living skills e.g. self-care, independent living skills, safety skills Relationship/social skills Self-regulation skills/understanding emotions Transitioning program e.g. to school Other Please Choose* Assessment Consult Where is the preferred location of support? (OT)* Home School Work How many hours of Occupational Therapy support required if known?Additional Comments (OT) Positive Behaviour SupportSpecialist Behaviour Intervention Support HoursBehaviour Management Planning & Training HoursSocial Skills Development HoursHave you/the client had a behaviour support plan previously?* Yes No Please provide details on previous behaviour support plan*Have you previously received Positive Behaviour Support services from another provider?*YesNoWho was the provider/providers of the previous Positive Behaviour Support services?What type of plan and when did it finish?*Are you / is the person physically aggressive?* Yes No Are you / is the person verbally aggressive?* Yes No Do you / does the person cause harm to themselves?* Yes No Do you / does the person damage property?* Yes No Do you / does the person exhibit harmful sexual behaviours?* Yes No Do you / does the person abscond from their home or supports?* Yes No Is the person on medication to modify their behaviour?* Yes No Are there any known restrictive practices in place?* Yes No Description of behaviours/restrictive practices* Speech TherapyWhat are the participant’s goals for Speech Therapy support?*Please Choose* Assessment Consult What support do you require? (Speech)* Understanding language Expressing themselves Articulation and speech clarity Alternative and augmentative communication (AAC) Play and interaction skills Social skills Mealtime management Other How many hours of Speech Therapy support required if known?Where is the preferred location of support? (Speech)* Home School Work Additional Comments (Speech) Early Childhood InterventionWhat are the participant’s goals for early childhood support?*What support do you require? (ECI)* Occupational therapy Speech Pathology Physiotherapy Developmental Educator Early childhood Educator Other Where is the preferred location of support? (ECI)* Home School Work How many hours of support are required if known? (ECI)Additional Comments (ECI) Social WorkWhat are the participant's goals for Social Work support?*What type of support(s) do you require? (Tick box as required)*Family and carer support/skill buildingIncreasing independence and support with life transitions (e.g. school, accommodation, etc.)Interpersonal skills and relationship buildingSupport with complex problem solvingRelationship and social skill developmentCounsellingRelaxation and mindfulness strategiesOtherPlease Choose* Assessment Consult Where is the preferred location of support?*HomeSchoolWorkOtherHow many hours of support are required (if known)?Additional comments Hydrotherapy/I Can SplashAt I Can Jump Puddles we offer Hydrotherapy and I Can Splash. Hydrotherapy is 1:1 with a Physiotherapist charged at the Physiotherapist rate. We also offer the "I Can Splash" program which is aimed at those transitioning to mainstream swimming. This is 1:1 with a Therapy Assistant charged at the Allied Health Assistant rate. If you have any questions about the difference please give us a call on 08 7085 3999. Preferred Sessions To Attend (Times Are Subject To Availability)* Adelaide Hydrotherapy Welland - Monday 4-6pm (Hydro w/ Physio) Adelaide Hydrotherapy Welland - Tuesdays 4-6pm (Splash w/ Therapy Assistant) Adelaide Hydrotherapy Welland - Thursdays 4-6pm (Splash w/ Therapy Assistant) Salisbury Aquatic Centre - Thursdays: 9:30-12:30pm (Hydro w/ Physio) The Aquadome, Elizabeth - Wednesdays: 3-6pm (Splash w/ Therapy Assistant) The Aquadome, Elizabeth - Fridays: 9:30-12:30pm (Hydro w/ Physio) The Aquadome, Elizabeth - Fridays: 9:30-12:30pm (Splash w/ Therapy Assistant) Noarlunga Aquatic Centre - Thursdays: 9:30-12:30pm (Hydro w/ Physio) The Arc Campbelltown - Wednesdays: 9:30am - 12:30pm (Hydro w/ Physio) Brief overview of NDIS plan/ supports currently in place (any Physiotherapy/ hydrotherapy input past or current)*Reason for NDIS plan*Does the participant have previous experience in the water?* Yes No Is the participant safe around water? How much supervision do they require in the water?*What are the participant’s hydrotherapy goals?*Does the participant require a doctor’s clearance to participate in hydrotherapy? Any recent hospitalisations or other relevant medical details?* Yes No Specific support needs to consider* Mobility requirements e.g. seating/ equipment Hearing/Visual Sensory Communication e.g. verbal/ non-verbal/ any AAC utilised, if yes, what system do they use? Health/ Allergies e.g. Epilepsy/ seizure management plan?/ Asthma or respiratory support needs?/ Anaphylaxis or allergies? Do you have an emergency response plan? Swallowing e.g. texture modification needs/ PEG or Nasogastric feeds? Behaviour Is the participant able to transfer independently?* Yes No If no, how do you transfer?*Will you require a hoist to enter the water?* Yes No Any risks to be aware of for the participant in an aquatic environment?*From 1-10 how confident are you in the water environment?* 1 2 3 4 5 6 7 8 9 10 From 1-10 how confident are you participating in hydrotherapy?* 1 2 3 4 5 6 7 8 9 10 Additional Comments (Hydro) Epilepsy / SeizuresExperience Epilepsy/Seizures?* Yes No When did your last seizure occur?*Do you have a seizure management plan?* Yes No AsthmaExperience Asthma?* Yes No How is your asthma managed?*Do you have an asthma management plan?* Yes No Anaphylaxis / AllergiesDo you have anaphylaxis / allergies?* Yes No Provide detail of allergies and management of these.*Do you have an emergency response plan?* Yes No Any other medical needs that need to be identified regarding hydrotherapy? (e.g. spasms, PEG or naso feeds etc).* Yes No If so, provide details.*Is a Doctor's clearance required for you to participate in hydrotherapy?* Yes No Have you had any recent hospitalisations?* Yes No Please provide relevant details*Medications currently taking:Any other medical information relevant to attending a hydrotherapy program?About You (Communication Skills)Do you use verbal language or communicate non-verbally?* Verbal Language Communicate Non-Verbally If you communicate non-verbally, what is your method of functional communication? (e.g. PECS, PODD, AAC, Key Word Sign, iPad app etc.)*Do you have a communication dictionary?* Yes No If yes, can this be accessed to learn about the best way to communicate with you?*Communication DictionaryMax. file size: 16 MB.About You (Behaviour of Concern)Describe what you might do when you are feeling upset or uncomfortable?*Are there any triggers or situations that can cause you to feel upset or uncomfortable leading to behaviours of concern?*Do you have any sensory needs that are important to be aware of? (e.g. loud noises, touch, bright lights, temperature etc.)*What strategies can assist you to regulate or feel better when experiencing difficulties?*Do you have a Positive Behaviour Support plan?* Yes No Positive Behaviour Support planMax. file size: 16 MB.About You (Mobility)Are you able to get in and out of the pool independently?* Yes No Do you need one of the following? Lifter Chair Ramp Hydrotherapy ProgramDo you have any previous hydrotherapy experience?* Nil Minimal Moderate Experienced Safety around water:* Not safe at all Has some understanding of water Is safe around water, but needs close supervision Very safe around water Anything else you would like to tell us about yourself / your child? I Can ExercisePlease select a session to attend - I Can Exercise*The Studio - West Beach, Fridays 1:30pm - 3:00pmWho will be accompanying the client to the session?*Are there any risks or concerns with group participation (e.g. behavioural concerns, mobility needs etc.)?* I Can Play SportPlease select a session to attend - I Can Play*Next Available SessionWho will be accompanying the client to the session?*Are there any risks or concerns with group participation (e.g. behavioural concerns, mobility needs etc.)?* I Can ExplorePlease select a session to attend - I Can Explore*Next Available SessionWho will be accompanying the client to the session?*Are there any risks or concerns with group participation (e.g. behavioural concerns, mobility needs etc.)?* I Can CookPlease select a session to attend - I Can Cook*Netley - Monday 18th December (9:30am - 10:30am)Next Available SessionWho will be accompanying the client to the session?*Are there any risks or concerns with group participation (e.g. behavioural concerns, mobility needs etc.)?* I Can RelaxPlease select a session to attend - I Can Relax*Next Available Session If you can't make all sessions, please contact our admin team Who will be accompanying the client to the session?*Are there any risks or concerns with group participation (e.g. behavioural concerns, mobility needs etc.)?* I Can CreatePlease select a session to attend - I Can Create*West Netley - Tuesday 3rd October - 9:30am - 10:30amWest Netley - Tuesday 19th December - 9:30am - 10:30amNext Available SessionWho will be accompanying the client to the session?*Are there any risks or concerns with group participation (e.g. behavioural concerns, mobility needs etc.)?* I Can RidePlease select a session to attend - I Can Ride*Next Available SessionWho will be accompanying the client to the session?*Are there any risks or concerns with group participation (e.g. behavioural concerns, mobility needs etc.)?*What bike/scooter will the client be bringing to the session?* I Can ThriveSession*Aberfoyle Park - Friday Weekly 19/5 to 9/6 (10am - 11am)Surrey Downs - Thursday Weekly 10/8 to 31/8 (10am - 11am)Aberfoyle Park - Friday Weekly 3/11 to 24/11 (10am - 11am)What is the client's age?*Who in your family will be participating in the group?*When is your child due to start school?*Do you know what school your child would likely attend?*Does your child currently attend Kindy or preschool? Which preschool or kindy?*How are you feeling about your child starting school?*Accessibility needs to support getting to the sessions safely?*Medical alerts/allergies*What would you like to get out of the group?*Do you have any concerns about your child starting school?*What best helps your child to thrive?*What might limit your child's participation in a family group setting?* Child VoiceSessionNext Available SessionWhat would you like to get out of the session?Who will be attending the session?Do you require child-minding services?Specific Support Needs to ConsiderCommunication e.g. Interpreter RequiredMobility Requirements e.g. Seating/EquipmentHearing/VisualPlease elaborate if needed Assistive Technology ConsultationPreferred Date*Next Available SessionWhat NDIS goals would you like to achieve with the assistive technology?*What is your budget for purchasing equipment?*What type of assistive technology are you looking for? (e.g. crash mats, small fidgets, gross motor equipment, visual schedules, sensory tent etc.)*Do you have equipment at home you find helps you to regulate or you enjoy using? This will help us with selecting the correct equipment to trial.* Therapy AssistantTherapist Name*Frequency + Day/Time - Please give at least 3 options (otherwise follow up is required)*Length of each session*Location of session (suburb + school/home/childcare etc.)*Length of program (No. of weeks)*Would the client be interested in participating in school holiday groups? Yes No What the client be interested in receiving 1:1 supports in the school holidays? Yes No Additional InformationTA Program (File needs to contain TA Program in its file name)*Max. file size: 16 MB. Functional Capacity AssessmentWhat is the purpose of this functional capacity assessment?*When does this functional capacity assessment need to be completed by?* DD slash MM slash YYYY What support do you require?* Independent living skills e.g. self-care, independent living skills, safety skills Relationship/social skills Self-regulation skills/understanding emotions Building self-esteem: Transitioning program e.g. to school Other Where is the preferred location of support?* Home School Work How many hours of functional capacity assessment required if known? Training PackagesPlease elaborate on what is required* Referrer DetailsReferrer Name* First Last Referrer Phone*Referrer Email* How did you hear about I Can Jump Puddles?* Allied Health Provider Another I Can Jump Puddles Client Capacity Email Clickability Closing the Gap Expo Community Directory Disability Service Provider Drove past our Office/Signage Education - Child Care Education - School Education - University Family/Friend Gov Agency - DCP Gov Agency - NDIA Internal Referral Internet Search Kismet LinkedIn Medical - GP Medical - Hospital Newspaper Radio Ready Set Connect Innovate Social Media CommentsConflict Of Interest Declared* I acknowledge that a conflict of interest has been declared to the client. CAPTCHACompanyThis field is for validation purposes and should be left unchanged.
