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Register – Building Buddies

Register – Building Buddies

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Select a session
Child Name*
First Last
Child DOB*
MM slash DD slash YYYY
Parent Name*
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone number*
Email Address*
Preferred method of contact*
Preferred contact time
Can we use the above information as an emergency contact?*
- Yes
- No
If no, please provide an alternative contact:*

Are you of Aboriginal or Torres Strait Islander origin?
- Yes
- No
- Prefer not to say
Do you have any religious or cultural needs?*
- Yes
- No
If yes, please comment*
Do you have any Guardianship or Financial Administration Orders in place?*
- Yes
- No
If yes, please comment*
Are there any other health issues or allergies we need to be aware of?*
- Yes
- No
If yes, please comment*

Diagnosis*
What does your child hope to gain from this group?
What funding do you receive?*
- NDIS - Funds allocated to Rocky Bay
- NDIS - Other
- WANDIS
- Block Funding
- Medicare Referral
- Privately Funded
- Unsure
If NDIS Other, how is your plan managed:*
- Self-Managed
- Plan Managed
What is your plan manager's email?*
What is your NDIS number?
Plan start and end date:
Do you currently receive services from a Rocky Bay Therapist?*
- Yes
- No
Did your therapist refer you to this group?*
- Yes
- No
Which Rocky Bay therapist referred you to this group?
Is your child aged between 8 - 12 years?*
- Yes
- No
Is a goal relating to social skills and/or making friends covered in your child's plan?*
- Yes
- No
- Unsure
Comment*
Is your child able to participate with minimal support in a group setting?*
- Yes
- No
- Unsure
Comment*

Is your child able to follow complex verbal instructions?*
- Yes
- No
- Unsure
Example - Your child will be able to follow the instruction, "You need to place the green brick on the front left corner of the grey base plate."
Comment
Is your child able to attend to a task with minimal support?*
- Yes
- No
- Unsure
Comment*
Is your child able to regulate their emotions & behaviours?*
- Yes
- No
- Unsure
Comment*
Does your child behave in a safe manner towards other is a group setting?*
- Yes
- No
- Unsure
Comment*
Is your child able to explain concepts and deliver instructions to others?*
- Yes
- No
- Unsure
Example - Prepositions and spatial concepts such as: on top, under, next to, front, back, behind, between, rotate, left and right.
Comment*
Does your child have a tendency to become aggressive, anxious or run away?*
If yes, please provide details of any strategies you have in place to manage/reduce these tendencies.

Does your child require any support with communication?*
- Yes
- No
What type of device does your child have?
Is there anything else we need to know before attending the group?*
Would you like to keep up to date with Rocky Bay news?*
- Yes
- No
Comments
This field is for validation purposes and should be left unchanged.

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60 McCabe Street,
Mosman Park, WA 6012

Phone (08) 6282 1900

ABN 66 028 387 386
ACN 636 892 898

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Phone
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NDIS PROVIDER NUMBER
4050002098

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Rocky Bay acknowledges the traditional owners of country throughout Australia and their continuing connection to land and community. We pay our respect to them and their cultures, and to elders past and present.

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