First Focus Application Form

Participant Details
Child's Name*
First Last
Gender:*
- Male
- Female
- Non-Binary
- Intersex
- Other/Unspecified
- Not known
Date of Birth*
Age
Sorry, only children aged 2-5 years are eligible for this program.
Residential Address*
Street Address City ZIP / Postal Code
Is this child currently accessing NDIS funding?*
- Yes
- No
Is this child currently under the care of the Department of Child Protection and Family Support?
- Yes
- No
Sorry, only children who do not have NDIS funding are eligible for this program.
Is this child Aboriginal or Torres Strait Islander?*

Developmental Concerns

You can find detailed information about child development on the Raising Children Network website: (links open in new tabs)
Child development at 3-4 years | Child development at 4-5 years
Select the areas of development you are concerned about for your child:*
- Movement/gross motor skills
- Fine motor skills
- Social skills
- Emotional regulation
- Language/communication
- Cognitive skills
- Other
Please detail your observations and examples of delayed development in these areas:*
Please list any medical conditions or health concerns:
Please outline why you would like to access the First Focus program:*

Consents & Agreement
I give consent for my child to:
- participate in the First Focus program
- be photographed/recorded for therapeutic and training purposes
- be photographed/recorded for promotional purposes
How did you hear about the First Focus program?*
GP or health/medical practitioner:
Please provide details:
By submitting this application you agree to the following terms and conditions:
- Approved participants must attend all sessions
- A parent or guardian is required to remain on site at all times during program sessions and assessments
- Therapy Focus will share de-identified participant information, including assessment and report data, with program funders Telethon and Stan Perron.
Agreement*
- I agree to the terms and conditions

Additional Emergency Contact