One-on-One Application Form

Your information

Parent First Name

Parent Last Name

Phone Number

Email Address

How did you hear about us?

Would you like a Health Insurance invoice?

YesNo

The following companies are only available for claims AHM, BUPA, HCF and Medibank.

Do you require a NDIS invoice?

YesNo

If yes, include NDIS number

Your child's information

Child First Name

Child Last Name

Child's Date of Birth

Does your child suffer from allergies?

YesNo

If yes, include some details

Child's favourite style or material of art?

Has your child had a diagnosis? If so, what was it and when was it given?

Does your child have difficulty sitting still for more than 20 minutes?

How would you rate your child's energy levels 1-5? (5 being the most energetic).

If there is a sudden unexpected noise, does your child over-react?

Does your child work well in a group?

Are there any social/emotional topics that your child deals with well?

Are there any social/emotional topics your child struggles with?

What happens for your child when they are upset? How do they show you that they are stressed or upset?

Please add any additional information that you think may be relevant regarding the discussion of social/emotional topics and the use of art materials in a group setting?

Success!

Thank you for your application. The Creative Connection team has received your application and will get back to you shortly with more information.

In the meantime find answers to your questions on our FAQ's or head back home.

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