First Focus Application Form

*Please note the program is currently closed. Complete the form below to be added to the waitlist for future intakes.
Participant Details
Child's Name*
First Last
Gender:*
- Male
- Female
- Non-Binary
- Intersex
- Other/Unspecified
- Not known
Date of Birth*
Day
Month
Year
Age
Please note, 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
Please note, only children who do not have NDIS funding are eligible for this program.
Is this child currently under the care of the Department of Child Protection and Family Support?
- Yes
- No
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 (e.g. walking, running, jumping, throwing)
- Fine motor skills (e.g. writing, holding cutlery, fastening buttons)
- Social skills
- Emotional regulation
- Language/communication
- Cognitive skills (e.g. attention, memory, problem-solving)
- 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 and Agreement
I give consent for my child to:
- participate in the First Focus program
- be photographed/recorded for therapeutic and training purposes
  (For internal use by Therapy Focus clinicians and staff only)
- be photographed/recorded for promotional purposes
  (Instances where photographs/recordings may appear include, but are not limited to, Therapy Focus and Telethon's website, social media profiles, digital and printed publications)
How did you hear about the First Focus program?*
GP or health/medical practitioner: (if applicable)
This field is hidden when viewing the form
GP or health/medical practitioner: (if applicable)
Please provide details: (if applicable)
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