HomeRegister – Building Buddies Register – Building Buddies Step 1 of 5 20% Select a location*RockinghamPKC CockburnDuncraigAscotMandurahExpression of interestSelect a date*January 2023 - 16 January to 20 JanuaryApril 2023 - 17 April to 21 AprilJuly 2023 - 10 July to 14 JulyOctober 2023 - 2 October to 6 OctoberSelect a time slot*Morning - 9:30am to 11:30amChild 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 AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Phone number* Email HiddenEmail Address Preferred method of contact*PhoneEmailPreferred 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 NameThis field is for validation purposes and should be left unchanged. Δ
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