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Intake form for under 18s

Client intake form for under 18s

Personal details

Emergency contact details

Other information

Parent/Guardian consent

to participate in individualised services provided by Australian Inclusion Network.

I understand that for the service to be successful I must also commit to working collaboratively with Inclusion WA staff. This includes being available in person for meetings and by phone or email to discuss the details of my child’s services.

I also give permission for: (please tick all that apply)
I understand that I give my permission as parent/guardian for the applicant to participate in individualised services provided by Australian Inclusion Network. services are designed for my child to establish sustainable, independent and on-going participation in an activity or skill relating to a goal. For this to occur my child and their support network will need to work together to address time commitments, transport and financial requirements.

Disclaimer:
Please be aware that all the information provided in this form is essential in assisting us with the application and subsequent processes. It is therefore imperative that all areas of the form are addressed. Inclusion WA is not responsible for any incidents that may arise due to insufficient information provided on this form. Any additional information that could affect our capacity to work with the applicant should also be provided as an addendum to this application.