Once we receive this form, our Admin team will contact you to discuss our pricing and book you in for assessment, review or therapy sessions.

Guardian 1 Full Name

First Name

Last Name

Guardian 2 Full Name

First Name

Last Name

Contact Email

Phone

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Childs Full Name

First Name

Last Name

Childs Date of Birth

Languages Spoken at Home

Emergency Medical Information:

Allergies (food, medication, other):

Diagnosis or Developmental Delay:

Current Medications:

Any known medical conditions:

Individual Modifications or Accommodations:

Any individual modifications or accommodations the child may require:

Any behavioural concerns or considerations:

Strategies that work well with the child:

Please select below the group/s you would like to enrol your child in:

Please note, we will do our best to accomodate your preferred days/times for therapy.

Playgroup (2-4 years): Tuesday 9:30-11 AM (2-4 Yrs)

Sensory, movement and music (3-4 years): Wednesday 9:30-11 AM (2-4 Yrs Social Skills & Music and Movement)

School Readiness (4-5 years): Thurs 9:30-11 AM (4-6 Yrs, School Readiness)

Wed 3:30-4:30 PM (5-7 Yrs, Circus & Social Skills)

Wed 4:30-5:30 PM (7-9 Yrs, Circus & Social Skills

Thurs 3:30-4:30 PM (5-7 Yrs, Circus & Movement Group)

Thurs 4:30-5:30 PM (7-9 Yrs, Circus & Movement Group)

Any Additional Comments?