* 1. Name of child and parent (carer):

* 2. Frequency of service delivery Term 4:

* 3. Day(s) of the week

* 4. Location(s) for service delivery:
NB: Fees apply for all outreach services

* 5. Service model options:

* 6. Best option for confirming service delivery arrangements:

* 7. Outstanding equipment loans:

* 8. I have an outstanding equipment loan and would like to return it prior to Term 4 2013, commencement:

* 9. Assessment

* 10. Advocacy and planning support. I require an individual appointment:

T