Term 1 Everyone Group » Next Level Collaboration

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Emergency Contact 1 Phone(Required)

Emergency Contact 1 Email(Required)

Emergency Contact 2 Phone

Emergency Contact 2 Email

Preferred Name(Required)

Are there any court orders in place regarding your child?

What are your child's current interests and/or hobbies?(Required)

How is your child feeling about coming to Next Level Collaboration?(Required)

What does your child hope to get out of attending Next Level Collaboration?(Required)

Please describe your main goals for your child(Required)

Provide overview of plan(Required)

Who does your child currently live with at home (names and relationships)?(Required)

Is there a language other than English spoken at home?(Required)

What school does your child attend?(Required)

What school grade/year is your child currently in?(Required)

Please provide any comments related to your child’s progress at school below(Required)

Is your child currently engaged with any other health professionals or supports (e.g. speech pathology, occupational therapy, psychology)?(Required)

If your child has any current diagnoses, please list them and the age at which they were diagnosed below

Does your child have any allergies?(Required)

Please list any medications your child takes regularly

Please describe any other health conditions, major accidents, or hospitalizations below(Required)

Strengths and Interests Profile

Next Level Collaboration have adapted this section from Aspy & Grossman (2011) to help us learn more about our participants’ areas of strength and interest. Knowing what our participants are good at or enjoy doing helps us build from their strengths and provide support where needed. Please fill out your child’s relevant areas of strength, skills, and interests for each category (up to 100 words).

Example:

Prefers to interact with adults
Enjoys talking to peers about her favourite video games
Is most comfortable in social settings with a few close friends

Behaviour, interests, and activities

Example:

Has a strong interest and extensive knowledge about animals, especially sea creatures
Handles the transition from lunch time to silent reading well
Works best in a structured and familiar setting

Behaviour, interests, and activities(Required)

Example:

Has a wide vocabulary when motivated to speak
Is most engaged in conversation when the topic is related to her interests
Prefers written communication or gesture if he does not want to speak

Communication(Required)

Example:

Tolerates the noise during PE class in the school gymnasium
Enjoys sensory tools that can be squished or stretched
Eats a variety of food

Example:

Maintains a strong attention span when using their iPad
Can remember a large number of facts about owls
Prefers multimedia learning supports such as diagrams and video content

Example:

Demonstrates good balance and enjoys gymnastics
Prefers touch screen or motion controls when playing games
Is aware of her environment when she wants to stim

Example:

Copes best when he is rested and comfortable
Can recognise when she is feeling angry or frustrated
Uses breathing exercises to self-regulate when he feels anxious

Parent/Guardian’s Signature(Required)

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Connecting Product

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Program Name

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Term 4 Everyone Group Zoom Booking

Strengths and Interests Profile

Social

Behaviour, interests, and activities

Communication

Sensory

Cognitive

Motor

Emotional

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