Social Interaction Groups

Social Interaction Groups

Expression of Interest Form
Name of Participant *

First NameLast Name
Gender and Pronouns
D.O.B:
School and Current year level (where applicable)
E-mail*
Mobile Phone Number:*
Parent Name (if under 18):
How did you hear about the groups?
Which afternoons during the week are you available to attend a group?
For after school times, what is the earliest time you would be able to arrive at our clinic for a group?
Privacy Policy and Health Information Collection Statement

Before you can be seen at our practice, you need to be aware of what information is collected, why we collect it, and under what conditions information is disclosed.

Please review our Privacy Policy and Collection Statement before proceeding.

If you do not understand or have questions about our Privacy Policy, please stop and call 0422 295 513 for clarification.

By submitting this form you are agreeing that you have read, understood and accepted our Privacy Policy and Collection Statement.
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