School Holiday Social Skills Program July 6 July 9 Mill Park

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1 School Holiday Social Skills Program July 6 July 9 Mill Park Sounds Right Speech Pathology will be offering an Intensive Social Skills Program that will run for four days over the July School holidays. The program will aim to promote: Positive Interactions Body awareness Playing fairly Social Interactions Going first (and last) And much more! Your child will be placed in a small group of up to 8 children. Groups will be staffed by Speech Pathologists all trained in the area of Autism Spectrum Disorders. Your child will be placed in a group that most suits his/her needs. Three sessions will run each day of the week, with your child attending one session per day. Session one 9:30 11:00 Preschool Ages 3-4 Session two 12:00 1:30 Preschool and School Aged Ages 4-6 Session three 2:30 4:00 School Aged Ages 7+ Limited spaces available Early bird closes May 31 The program is suitable for children with social difficulties, high functioning Autism, PDD-NOS or Asperger s Syndrome. Cost $ (Private clients) $ (DSS clients already receiving services through Sounds Right) $ (DSS clients who are not receiving services through Sounds Right Speech Pathology) If you would like more information, please call or refer to our website: If you would like your child to enrol, please fill in the paperwork available from the website and return with appropriate documentation to 7/7 Development Boulevard Mill Park, Phone applications are not accepted.

2 Does your child currently receive speech therapy from Sounds Right Speech Pathology? Yes No Section A: Child s Information Child s Name: DOB: Age Address Post Code Parents Names Phone Number (Home) (Mobile) Does your child have any allergies? Yes No If yes, please list: Does your child need to carry an EpiPen? Yes No If yes, please ensure your child brings their Epi Pen to their sessions If your child is diagnosed, please tick: Autism Asperger syndrome PDD-NOS ADHD Other (please list) Does your child have any recent speech and/or language assessments? Yes No If yes, please attach copies Section B: Educational History My child attends: Child care Kindergarten School Other (Please list): Name of childcare/kindergarten/school: Does your child have an Integration Aide? Yes No If yes, please indicate the number of hours supported by Integration Aide:

3 Section C: Behaviour Please tick the box/boxes which best describes your child s behaviour. My child is: Placid very gentle nature Social tries to socialise with others Gets anxious easily Can be impulsive Rigid/Controlling Physically aggressive (Please describe) Verbally aggressive (Please describe) Oppositional Withdrawn/Quiet Other (Please describe) Please tick the box/boxes which best describe difficulties that your child is currently having in social situations: My child has difficulty: Understanding body space Maintaining eye contact With winning and losing Staying on topic Making friends Initiating conversations Other (Please list)

4 What skills would you like your child to learn when attending the group? What are your child s special interests? Section D: Advertising How did you hear about this program? Internet search (e.g. Google) Website School Newsletter (Please list school) Early Intervention Centre (Please list) Referral (Please indicate) Would you like to receive information from Sounds Right Speech Pathology regarding upcoming events? Yes No If yes, please include your address

5 Section E: Payment Who will be responsible for the payment of the program? Self FaHCSIA (Please provide a copy of your FaHCSIA letter from Autism Victoria) Please note that Medicare will not cover the cost of Group programs HICAPS facilities are available for private payments that have Private Health Insurance Please note: Please note that: Full payment is required to confirm your child s booking There will be a late fee of $30 if application is received after May 31 Phone applications are not accepted Paperwork must be filled in correctly before a position is offered Positions offered will be based on a first in basis No refunds will be provided for change of mind $ cancellation fee will apply if a cancellation is made Please note FaHCSIA does not cover the cost of cancellations Once a position has been offered to your child you will receive a phone call confirming their place. Full payment will then be required to secure your child s position. I have enclosed the following: Letter from FaHCSIA (For FaHCSIA clients new to Sounds Right Speech pathology) Any recent Speech Pathology reports/assessment results (if available) Please return completed form & attached documentation to: Sounds Right Speech Pathology 7/7 Development Boulevard, Mill Park, Vic, 3752