Client Details:

First name

Last name

Birthday

Parent / Carer Details:

First name

Last name

Phone

Email

Country/Region

Address

City

Zip / Postal code

Financial information

Funding Source:

NDIS Self Managed

NDIS Plan Managed

Private

NDIS Participants Only:

NDIS Number

Plan Start Date:

Plan End Date:

Payer / Plan Manager

NDIS Goals

Relevant Medical Information

Multi choice

Please specify any diagnoses, pre existing &/or new injuries we need to consider in how we plan the sessions

Additional Information

Location:

Pacific Pines - Thursday

Pimpama - Friday

Age group:

4-8 years old: 3:45-4:45

8-15 years old: 4:50 - 5:50

I am interested in:

Term 1, 2025

EOI for school holiday program

Term 2, 2025

More Information

If the program is full would you like to be added to the waitlist?

Yes

No

What Goals Would You Like To Work Towards With Sense Rugby?

Taking turns with peers

Making friends and learning how to play nicely together

Staying focused and listening carefully to what’s happening around me

Understanding my feelings and staying calm, even if things don’t go my way.

Joining in with my teammates and working together as part of a team

Learning what’s expected in different situations and knowing what to do if something surprising happens.

Understanding personal space and respecting others' boundaries so everyone feels comfortable.

Finding ways to use sensory tools and activities with others to help my body calm down and feel comfortable.

Other goals:

Photo & Video Consent

Do you give permission for images, videos, and/or audio recordings of the participant to be used on social media and public platforms? I understand that this permission is valid indefinitely and is not restricted by time or location.

Yes

No

Consent Acknowledgement:

By submitting this form, I consent to the collection, storage, and use of my personal information by Beelieve Paediatric Therapy Pty Ltd in accordance with their Privacy Policy. I understand that my details will be used solely for the purpose of providing services and communication related to my therapy and care needs.

Expression of Interest - Therapy during 24/25 End of year holidays