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(07) 3102 1366
ONLINE ENQUIRY
Secret Agent Society Group Registration Form
Home
Social and Emotional Group Therapy Programs
Secret Agent Society Group Registration Form
Please enable JavaScript in your browser to complete this form.
Child's Full Name
*
First
Last
Child's Date of Birth
*
Gender
*
Male
Female
Nonbinary / Gender Diverse
Prefer not to respond
Preferred Pronouns
*
He/Him
She/Her
They/Them
Other
Child's Age
Residential Address
Caregiver Information:
Primary Caregiver Full Name
*
First
Last
Primary Caregiver Relationship to Child
*
Primary Caregiver Phone
*
Primary Caregiver Email
*
(Optional) Secondary Caregiver - Full Name
First
Last
Secondary Caregiver Relationship to Child
Secondary Caregiver Contact Phone Number
Secondary Caregiver Contact Email Address
Additional Caregivers
Please provide the full name and contact information for any additional caregivers who will be participating in the program:
School Information
School /Grade
School contact details
School teacher details (name, year level, email address)
Child's Medical Information
Please specify any diagnoses your child has and who provided the diagnosis (Paediatrician, Psychiatrist, Psychologist, Other (please specify), etc)
Does your child have regular contact with any other professional(s) or government agencies? If yes, please describe and provide contact details if possible.
Child’s Medical History (tick all that apply)
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 currently prescribed medications)
Child's Mental Health Information
Does your child have any special interests? *
Please list three major difficulties that your child is experiencing*
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:
address) * child
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.
Please select billing for the Group Program:
*
NDIS Plan Managed
NDIS Self Managed
Mental Health Care Plan
Private
Other
If Other, please indicate below:
If NDIS Plan Managed, please provide your Plan Manager's name and contact email address for forwarding invoices.
Signature of Primary Caregiver
*
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
