Register Here Listen Referral & Registration Form Step 1 of 27 0% 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. Are you a new or existing client?* New Existing Services for RequestServices for Request* Support Coordination Specialised Support Coordination Developmental Education Positive Behaviour Support Early Childhood Intervention Occupational Therapist Speech Pathologist Physiotherapy Counselling Hydrotherapy Dietitian I Can Exercise I Can Cook I Can Play I Can Explore I Can Relax Client DetailsSalutation* Mrs Ms Mr Dr Prof. Birth Date (must use calendar to select)* DD slash MM slash YYYY Name* First Last Preferred Name Gender* Female Male Intersex Declined to Answer NDIS Number*PhoneEmail Address* Mobile*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 ContactName* First Last Email* Phone*Relationship to Client* Medical DetailsPrimary 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 SyndromeOther, please specify: Other Medical/Health Conditions 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* MM slash DD slash YYYY Funding Management* NDIA Managed Plan Managed Self-Managed Plan Manager Name* Email address for invoices Please upload NDIS PlanMax. file size: 128 MB. SafetyIs 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?* 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?*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 How many hours of physiotherapy support required if known?Additional Comments (Physio) DieteticsBrief overview of NDIS plan/ supports currently in place (any Dietetics input past or current)*What are the participant’s goals for Dietitian support?*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 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 Building self-esteem; Transitioning program e.g. to school Other 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*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 PathologyWhat are the participant’s goals for Speech Pathology support?*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 Where is the preferred location of support? (Speech)* Home School Work How many hours of Speech Pathology support required if known?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) HydrotherapyBrief overview of NDIS plan/ supports currently in place (any Physiotherapy/ hydrotherapy input past or current)*Reason for NDIS plan (Hydro)*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) I Can ExerciseSession*Next available sessionBrief overview of NDIS Plan/supports currently in place?*Reason for NDIS plan (ICExercise)*Does the participant have previous physical acitivity experience/group education participation? (positive experience? If not, why?)*Does the participant have any physical exercise as part of routine at home currently (experience with gym equipment etc.)?*What would you like to get out of the I Can Exercise Program?*Support required? (ICExercise)* Mobility requirements e.g. seating/equipment Hearing/visual Sensory Communication e.g. verbal/non-verbal Health/Allergies Swallowing Behaviour Are you able to transfer on and off a bike?* Yes No Are you able to transfer on and off the floor?* Yes No How many minutes would you be able to walk before you needed a rest?*What type of physical activity do you enjoy?*Any risks to be aware of in regards to being involved in a gym environment?*How confident are you with using gym equipment (1-10)?* 1 2 3 4 5 6 7 8 9 10 How comfortable do you feel participating in physical activity (1-10)?* 1 2 3 4 5 6 7 8 9 10 I Can PlaySession*I Can Play - 7/8/2022-11/9/2022 - West - 10:00 AMI Can Play - 7/8/2022-11/9/2022 - West - 11:00 AMI Can Play - 3/8/2022-7/9/2022 - North - 4:00 PMBrief overview of NDIS Plan/supports currently in place? (ICP)*Reason for NDIS Plan (ICP)*Does have participant have previous physical activity experience/group education participation (positive experience? If not, why?)?*Does the participant have any sport or physical exercise as part of routine at home currently? (experience with sports equipment etc.)*What would you like to get out of the multi-sports session?*Support required? (ICP)* Mobility requirements e.g. seating/equipment Hearing/visual Sensory Communication e.g. verbal/non-verbal Health/Allergies Swallowing Behaviour Sports or physical activities you enjoy/ would like to try at I Can Play?*Who will be accompanying you to the session? (ICP)* Any risks to be aware of in regards to being involved in a sports group in a gym environment?*How confident are you with understanding different sports equipment and its purpose? (1-10)* 1 2 3 4 5 6 7 8 9 10 How comfortable do you feel participating in a physical activity group? (1-10)* 1 2 3 4 5 6 7 8 9 10 How would you rate your fatigue/tiredness levels after 60min of activity? (1-10)* 1 2 3 4 5 6 7 8 9 10 I Can ExploreSession*SOUTH - Tuesday 11 October 9:30am - 11:30am (4-7 years)SOUTH - Tuesday 11 October 1:00pm - 3:00pm (8-14 years)NORTH - Wednesday 12 October 9:30am - 11:30am (4-7 years)NORTH - Wednesday 12 October 1:00pm - 3:00pm (8-14 years)Overview of NDIS Plan/ supports currently in place (any OT input, past or current?) (ICExplore)*Reason for NDIS plan? (ICExplore)*Does the participant have previous group education participation experience (positive experience? If, not why)?*Does the participant have any nature exposure as part of their current routine at home?*What would you like to learn in an I Can Explore session? Any specific activities you enjoy or would like to try in nature?*Support required? (ICExplore)* Mobility requirements e.g. seating/equipment Hearing/visual Sensory Communication e.g. verbal/non-verbal Health/Allergies Swallowing Behaviour Who will be accompanying you to the session? (ICExplore)* Are there any risks to be aware of in regards to the participant accessing an open, natural environment e.g. national park?* How comfortable do you feel participating in a group (1-10)?* 1 2 3 4 5 6 7 8 9 10 How confident do you feel exploring outdoor spaces (1-10)?* 1 2 3 4 5 6 7 8 9 10 I Can CookSession*Halloween Scaretacular - October 14 - Session 1 - 6 - 10 year oldsHalloween Scaretacular - October 14 - Session 2 - 11-16 years oldHalloween Fright Night - October 28 - 5:00pm - 7:00pmOverview of NDIS Plan/ supports currently in place (any dietetic input, past or current?) (Cook)*Reason for NDIS Plan? (Cook)*Does the participant have previous cooking experience/group education participation (positive experience? If not, why?)*Any contribution to food preparation as part of routine at home currently?*What would you like to get out of the cooking group session?*Support required? (Cook)* Mobility requirements e.g. seating/equipment Hearing/visual Sensory Communication e.g. verbal/non-verbal Health/Allergies Swallowing Behaviour Any risks to be aware of in regards to the kitchen e.g. working with knives, being around hot elements?* What foods do you enjoy and are there any specific foods you are interested in learning to prepare?* Who will be accompanying you to the session? (Cook)* How confident are you in the kitchen environment (1-10)?* 1 2 3 4 5 6 7 8 9 10 How comfortable do you feel safely using kitchen utensils (1-10)?* 1 2 3 4 5 6 7 8 9 10 How confident do you feel to prepare a meal on your own (1-10)?* 1 2 3 4 5 6 7 8 9 10 I Can RelaxSession*Monday 10 October - 10:00am - 10:30am - 3-5 years oldMonday 10 October - 11:00am - 12:00pm - 6-12 years oldMonday 10 October - 2:00pm - 3:00pm - 13-17 years oldAny injuries or mobility conerns?* Any sensory processing challenges that should be considered (e.g. over-responsive to noise, bright lights)?* Any strategies to support regulation and participation?* Any behavioural concerns that may be relevant when participating in a group?* Any previous group experience?*Any previous yoga experience?* 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 Clickability 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 Medical - GP Medical - Hospital Newspaper Radio Social Media Do you wish to be EXCLUDED from organisational updates and bi-monthly publications? Yes CommentsCAPTCHAPhoneThis field is for validation purposes and should be left unchanged.
