ADHD and Neurodivergent Skills Sessions

Contact Name *

First Name

Last Name

Client Name *

First Name

Last Name

Age of Client *

Under 10

10-14

15-20

21-30

31-40

41-49

50-59

60-69

70+

Do you have an NDIS plan

*we are unable to see clients under agency managed plans

No

Yes - self managed

Yes - plan managed

Fees for Service *

I have read and understood that services are not Bulk Billed and will attract a fee as highlighted in FAQ Fees section

Client consent

if you are referring another person:

they are aware I am making the referral

they consent to us contacting them to discuss the referral directly

I am their parent/guardian/carer

Preferred method of contact regarding your enquiry

Email

Phone Call