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(07) 5551 0251
(07) 3102 1366
ONLINE ENQUIRY
Secret Agent Society Group Registration Form
Home
Social and Emotional Group Therapy Programs
Secret Agent Society Group Registration Form
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Child's Information:
Full for Does
Full Name of Child
*
First
Last
Date of Birth
*
Gender
*
Male
Female
Preferred Pronouns
Age
Residential Address
School
Grade
School Contact Details
School Teacher Name/Year Level
Teacher Email Address
Caregiver Information:
Primary Caregiver Full Name
*
First
Last
Relationship to Child
*
Primary Caregiver Phone
*
Primary Caregiver Email
*
Secondary Caregiver Full Name
First
Last
Relationship to Child
Secondary Caregiver Phone
Secondary Caregiver Email
Additional Caregivers
Please provide the full name and contact information for any additional caregivers who will be participating in the program:
Medical and Developmental History:
Does your child have any diagnoses? (e.g., ASD, ADHD, anxiety)
Yes
No
If yes, specify the diagnosis and the professional who provided it:
Child’s Medical History
Acquired brain injury
Loss of consciousness
Epilepsy
Headaches / migraines
Frequent ear infections
TICS / Twitching
Self-injurious behaviour
Hydrocephalus
Asthma
Allergies / Anaphylaxis
Intellectual delay
Speech or language impairment
Developmental delay
Vision impairment
Hearing impairment
Other (please specify)
Please tick all that apply:
please specify
Medications
Please list all medications your child is currently prescribed:
Does your child have regular contact with other professionals or government agencies?
Yes
No
Single Line Text
Does your child have any special interests?
Social and Emotional Skills:
Please list three major difficulties that your child is currently experiencing:
1
2
3
What helps your child calm down when distressed?
Suitability for Group Participation:
Has your child had difficulties in group settings?
Yes
No
If yes, please describe
Does your child display any behaviours that may be disruptive in a group setting?
Yes
No
If yes, explain
Can your child follow group instructions independently?
Yes
No
If no, what level of support do they need?
Additional Information:
Are there any other challenges or information the facilitators should be aware of?
Parent/Guardian Consent:
I, the undersigned, give permission for my child to participate in the Secret Agent Society Group Program and agree to the terms and conditions as set by CBT Professionals.
*
I, the undersigned, give permission for my child to participate in the Secret Agent Society Group Program and agree to the terms and conditions as set by CBT Professionals.
Signature
Date
Submit
THREE CONVENIENT LOCATIONS
HELENSVALE
Homeworld Helensvale
Shop 51, 502 Hope Island Road
Helensvale, Qld 4212
(07) 5551 0251
NERANG
Prana Centre
Suite 3, 832 Southport-Nerang Road
Nerang QLD 4211
(07) 5668 3490
MOUNT GRAVATT
Mt Gravatt Medical Precinct
SE 105, 1808 Logan Rd
Upper Mount Gravatt QLD 4122
(07) 3102 1366
