Child's Name *

First Name

Last Name

I am interested in my child participating in: *

Phonics – Teach your child to read & spell with Sounds-Write, the gold standard of evidence based teaching

LEGO therapy – build social skills while having fun!

Funding *

Private Health

Medicare Chronic Disease Management Plan/Team Care Arrangement

Self funded

NDIS Self Managed

NDIS Plan Managed

My child's vocabulary is: *

My child is non-verbal

My child has a small vocabulary

My child has a moderate amount of words

My child's vocabulary seems to be age appropriate

My child's sentence length is generally: *

1 word only at a time

2 word sentences (e.g. "more juice")

3 word sentences (e.g. "I want more")

Long sentences

Long sentences & can tell stories/tell me what they did at school

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

I would like to receive individual therapy sessions from Kat's Speech Pathology during term time as well as the small group holiday program

Yes

No