Secret Agents Society

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* 1. What is your child age

7 years of age

8 - 10 years of age

11 - 12 years of age

13+ years of age

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* 2. My child has the ability to work independently and seek assistance when required?

Yes

Can not work independently but can ask for assistance

Can work independently but can not ask for assistance

Other (please specify)

None of the above

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* 3. Please indicate if your child has one or more than the following diagnosis

Autism Spectrum Disorder

Attention Deficit Hyperactivity Disorder (ADHD)

Anxiety Disorder

Oppositional Defiance Disorder (ODD)

Intellectual Disability

Learning Disability

None of the above

Other

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* 4. My child is able to follow more than two-step instructions

Yes

Other (please specify)

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* 5. My child can independently

Write year 4 level english

Read year 4 level english

Understand year 4 level english

Speak year 4 level english

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* 6. Can your child independently complete tasks with minimal prompting

Yes

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* 7. Have access to an electronic device such as an iPad or tablet and use it within sessions?

Yes

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* 8. Can independently navigate with some independence through an electronic device such as an iPad or tablet

Yes

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* 9. I consent for Cherished Minds Psychology to contact me and discuss the program. (Please indicate yes or no)

Yes

Secret Agents Society

Question Title

* 1. What is your child age

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* 2. My child has the ability to work independently and seek assistance when required?

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* 3. Please indicate if your child has one or more than the following diagnosis

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* 4. My child is able to follow more than two-step instructions

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* 5. My child can independently

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* 6. Can your child independently complete tasks with minimal prompting

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* 7. Have access to an electronic device such as an iPad or tablet and use it within sessions?

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* 8. Can independently navigate with some independence through an electronic device such as an iPad or tablet

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* 9. I consent for Cherished Minds Psychology to contact me and discuss the program. (Please indicate yes or no)

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* 10. Please comment your name, your childs, best contact number and time for one of our friendly psychologists to contact you.