Behaviour Therapy In-School Registration

Please complete this form to register your child for our in-school behaviour therapy program. All information will be kept confidential.

Student's first name

Student's last name

Student's date of birth

Month

Day

Year

Student's gender

Male

Female

Other

School name

Grade/year level

Commencement Year

Teacher's name (if known)

Primary Contact Information

Parent/guardian first name

Parent/guardian last name

Email address

Phone number

Emergency Contact

Emergency contact name

Emergency contact phone

Behavioural Concerns

Describe the specific behavioural concerns

Consent and Agreement

I understand that information may be shared with school staff involved in my child's care on my request

I agree to attend parent/guardian sessions as part of the therapy program on request

I understand that by submitting this form, that I agree to the terms and conditions of Kids Therapy Clinics Australia