* 1. Please state your name and your child's name.
Email contact details and best phone contact number.

* 2. How can I best contact you?

* 3. When can I best contact you?

* 4. If I cannot meet a specified appointment time may I send you a text message prior to the start of business to cancel?

* 5. Do you have access to a computer and printer to download information, reports or therapy materials?

* 6. I am interested in computers and technology however I am not skilled at using emails or the internet.

* 7. I work on the following days and times. State when you do not want to be disturbed (in other)

* 8. I do not work, however I am busy attending to other matters on

* 9. My child is unavailable on the stated days and times due to prior commitments

* 10. The best days and time for service delivery for my child are
The nominated location of service delivery is stated in OTHER

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