HomeRegister – Tech Talkers Register – Tech Talkers Step 1 of 425%Select a sessionTerm 4 - Mandurah - Wednesdays 10:00am to 12:15pmExpression of interestParent or Carer Name* First Last Phone number*Email Address*Preferred method of contact*EmailPhonePreferred contact timeAddress* 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 Customer Name* First Last Customer date of birth* MM slash DD slash YYYY Diagnosis*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*Are there any other health issues or allergies we need to be aware of?* Yes NoIf yes, please comment* 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 a goal relating to communication covered in your plan?* Yes No UnsureComment*What do you hope to gain from the group? Do you have a communication device or system?* Yes NoIf yes, what type of device do you have?Do you have access to the communication device or system (i.e. hands, eye gaze, scanning)?* Yes NoIs there anything else we need to know before attending the group?*Comment or MessageWhere did you hear about Tech TalkersEmail - Rocky BayEmail - OtherFacebookGoogle SearchTherapistRocky Bay websiteWord of mouthOtherWould you like to keep up to date with Rocky Bay news?* Yes NoCommentsThis field is for validation purposes and should be left unchanged.