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Register – Gaming Group

Register – Gaming Group

Step 1 of 5

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Select a session*
Do you have the Bedrock edition of Minecraft?
- Yes
- No
- Unsure
If you answer No or Unsure, a therapist will contact you to discuss your registration. Due to the use of a Minecraft server, you will need to already own the Bedrock edition of Minecraft (not the Java edition).
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 10 - 17 years?*
- Yes
- No
Is a goal relating to social interactions, making friends, flexible thinking and/or self-regulation covered in your child's plan?*
- Yes
- No
- Unsure
Comment*
Does your child have emerging skills in understanding the thoughts and feelings of themselves and others?*
- Yes
- No
- Unsure
Comment*

Is your child able to communicate their thoughts and wants to others within stressful situations?*
- Yes
- No
- Unsure
Comment
Can your child work within a group environment?*
- Yes
- No
- Unsure
Comment*
Does your child behave in a safe manner towards others in a group setting within stressful or frustrating situations?*
- Yes
- No
- Unsure
E.g. Character dying within a Minecraft game.
Comment*
Do you (or anyone else) support your child to regulate their emotions within stressful or frustrating situations?*
- Yes
- No
- Unsure
E.g. Character dying within a Minecraft game.
Comment*
Does your child have a behaviour support plan?*
- Yes
- No
- Unsure
If yes, can our facilitators have access to the plan?*
- Yes
- No
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?
Please confirm that you are able to attend all sessions*
- Yes
- No
- Unsure
Comment*
Is there anything else we need to know before attending the group?*
Where did you hear about Gaming Group
Would you like to keep up to date with Rocky Bay news?*
- Yes
- No
Phone
This field is for validation purposes and should be left unchanged.

your partner in possibilty

contact us

60 McCabe Street,
Mosman Park, WA 6012

Phone (08) 6282 1900

ABN 66 028 387 386
ACN 636 892 898

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Comments
This field is for validation purposes and should be left unchanged.

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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