HomeRegister – Milo Social Skills Register – Milo Social Skills Step 1 of 520%Select a session*Cockburn | Term 1 - 18 January 2021 to 9 April 2021Mandurah | Term 1 - 18 January 2021 to 9 April 2021Gosnells | Term 2 - 12 April 2021 to 9 July 2021Rockingham | Term 2 - 12 April 2021 to 9 July 2021Cockburn | Term 3 - 12 July 2021 to 1 October 2021Gosnells | Term 3 - 12 July 2021 to 1 October 2021Duncraig | Term 4 - 4 October 2021 to 14 January 2022Cockburn | Term 4 - 4 October 2021 to 14 January 2022Expression of interestChild 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 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 Islands Country Phone number*Email Address*Preferred method of contact*PhoneEmailPreferred contact timeCan we use the above information as an emergency contact?* Yes NoIf no, please provide an alternative contact:* Are you of Aboriginal or Torres Strait Islander origin? Yes No Prefer not to sayDo you have any religious or cultural needs?* Yes NoIf yes, please comment*Do you have any Guardianship or Financial Administration Orders in place?* Yes NoIf yes, please comment*Are there any other health issues or allergies we need to be aware of?* Yes NoIf 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 UnsureIf NDIS Other, how is your plan managed:* Self-Managed Plan ManagedWhat 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 NoDid your therapist refer you to this group?* Yes NoWhich Rocky Bay therapist referred you to this group?Is your child over 5 years old?* Yes NoIs a goal relating to social interactions, understanding emotions and/or having conversations included in your child's plan* Yes No UnsureComment*Does your child behave in a safe manner towards people, objects and technology?* Yes No UnsureComment* Does your child have the ability to attend to a desktop task for 10 minute intervals?* Yes No UnsureCommentIs your child able to respond to yes/no questions?* Yes No UnsureComment*Is your child able to follow verbal instructions?* Yes No UnsureExample - 2 to 3 step verbal instructionsComment*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 NoWhat type of device does your child have?Please confirm that you are able to attend all sessions* Yes No UnsureComment*Is there anything else we need to know before attending the sessions?*Where did you hear about Milo Social Skills Therapy?Select your answerEmail - Rocky BayEmail - OtherKalparrinFacebookGoogle SearchTherapistRocky Bay websiteWord of mouthOtherWould you like to keep up to date with Rocky Bay news? Yes NoEmailThis field is for validation purposes and should be left unchanged.