TRIAL

Please fill in the form with the required information, we will contact you as soon as possible.
Parent's Name & Surname *
Child's First Name *
Child's Surname *
Child's Date of Birth *
What year will your child commence school? *
Email *
Phone *
Phone 2 (Optional)
What are your main concerns with your child? *
Does your child have a diagnosed disability or special needs?
If yes, please provide relevant details below
Is English your child's first language? If not, please specify. *
Does your child have any ongoing medical concerns? *
E.g. Allergies, asthma, etc. If yes, please provide relevant details.
Please note, children must be toilet trained to join the program. *
My child is toilet trained.
Please note, children must be immunised to join the program. *
My child is immunised (up to 3.5 - 4 yrs old).
I am aware that I am required to return an email questionnaire to help the ECIP team better support my child on his/her trial day.
Yes
Free Trial Preferred Date *
Topic and Focus Areas
Monday - Information Processing

Tuesday - Focus and Attention and Memory

Wednesday - Motor Skills

Thursday - Emotional Regulation and Impulse Control

Friday - Social Skills and power of play

*Please note: although we offer a daily focus our team ensures that we incorporate all 5 developmental areas every day.
How did you find out about us? *

* Once you receive your email questionnaire, an ECIP facilitator will be in contact to confirm your preferred trial date.

· Please arrive at Kids OT reception at 9am, and our staff will accompany you and your child to the ECIP room.
· Please return to the ECIP room at 11:50am to discuss the trial with the ECIP facilitators. Please note that parent supervision cannot be accommodated.
· Bring morning tea in a bag and a drink bottle- note that our ECIP room is a nut & egg free zone.