I:\Outreach\SCHOOL VISITS\Request Form SE Qld school visits 2011 .doc
OUTREACH SERVICES
VISIT REQUEST FORM
The Outreach team offers advisory visits to children with a diagnosis of Autism Spectrum Disorder/Asperger syndrome/autism, to schools, pre-schools and kindergartens. Please note that in certain circumstances where there is no educational placement, this service may take place in another setting – please discuss this with the team. These visits provide the opportunity to discuss issues and strategies with our Outreach staff to assist the child’s inclusion into his/her setting. Issues addressed may include behavioural and educational issues, communication, sensory processing, gross and fine motor skills and activities of daily living. Visits are usually 1.5 hours in duration and consist of observation and discussion time.
Following the visit, a written summary will be forwarded to the child’s family and the educational setting in which the visit took place.
VISITS WILL BE SCHEDULED THROUGHOUT THE YEAR ON A NEEDS BASIS
If you would like a visit please complete all sections of the request form below and return it to:
Autism Queensland Inc or Fax: (07) 3273 8306
PO Box 354, Sunnybank, Qld 4109
We will then contact you to arrange an appointment. There is no charge for this service.
If you would like any further information please contact Cathy McNeill on phone (07) 3273 0000
Please note that if form is not completed by all relevant parties and required information not attached, we will be unable to schedule a visit.
Refer to checklist attached to ensure all information is included.
Prior to returning form please check that all sections are completed and relevant information attached.
Copy of IEP (Individual Education Plan) for all children in educational settings
Details of verification and EAP status
Copy of letter of definite diagnosis or Verification of Autism Spectrum Disorder (Education Queensland form 3A) for newly diagnosed or very young children
Any other report or information you may feel will be helpful for our team.
Visit Request Form Regional
Issue: 4 May 2010 Page 2 of 4
CHILD DETAILS
Name:
DOB: School Year Level:
Postal Address:
P/Code:
Phone Number:
Parent/’s name/s:
Parent/’s email address:
Is the child a registered client of Autism Queensland? □ Yes □ No
PARENT/GUARDIAN CONSENT TO VISIT:
I ………….…………….…………………… give permission for relevant documents and information to be released regarding my son/daughter ………………………………….. to Autism Queensland to enable adequate preparation for the visit, to provide eligibility documentation to our funding body (NSO) and for Autism Queensland to discuss my child and share relevant information with his/her support team (e.g. local therapists, teachers) after the AQ visit. A visit summary will be provided to the parent/s /guardian/s and to the education setting in which the visit took place.
Data collected is stored and managed in AQ files and a secure data base according to our Data Management Policy. Please refer to the Autism Queensland Inc Privacy Information and Policies for further information regarding the collection, storage and sharing of information. This is available on our website, www.autismqld.com.au. Alternatively you may request a hard copy by contacting the Outreach Team.
Please tick one box to indicate below whether you give permission for the meeting regarding your child to proceed if you are unable to attend.
I DO give permission for the meeting regarding my child to go ahead if I am unable to attend.
I DO NOT give permission for the meeting regarding my child to go ahead if I am unable to attend.
By signing below I confirm that: I have read and understood the information provided about the outreach visit and the requirements outlined for access to, sharing and storage of information. I have legal custody of the above mentioned child and the legal authority to complete this document. I have provided any relevant custody documentation, where applicable.
Parent/Guardian Signature: Date: _________
SCHOOL DETAILS:
Name of School:
School Email:
Street Address:
P/Code:
Please provide any additional information which may assist us to locate you more easily (e.g. different campuses, parking with different street access etc)
Phone Number:
Fax Number:
Name and position of person requesting visit:
Class Teacher:
Contact Person:
Email:
Visit Request Form Regional
Issue: 4 May 2010 Page 3 of 4
Days and time of child attending:
Preferred times (While every effort is made to accommodate preferred times, these cannot be guaranteed.)
Times Unavailable: (e.g. school excursion etc)
Does the student access a special education service? If so please specify:
Special Education Program, please specify: ______________________ □ Special Education School
Therapy service, please specify: _________________________________ □ AVT service
Other, please specify: ___________________________________________
Please provide details of any other support services accessed by the student (eg. Services provided by non government organisations, private therapists, CYMHS etc):
EVIDENCE OF ELIGIBILITY:
The following information MUST be provided in order for students to be eligible for a visit.
1. Indicate which category applies and attach requested information (Tick ONE box only)
ASD Verification date: ____/____/____
Verified by (circle one): Education Qld/ Catholic Education/ ISQ
Primary verified impairment category (circle one): ASD/II/PI/HI/VI/SE/SLI/other _________
Other verified impairment categories (circle one): ASD/II/PI/HI/VI/SE/SLI/other _________
OR
For younger children or recently diagnosed – copy of letter of definite diagnosis or Verification
of Diagnosis (EQ form 3A)
OR
For students without an EAP:
Ascertainment Category ____________, Level ___________, Date ______________
Reason still ascertained: ___________________________________________________________
AND ___________________________________________________________
2. Individual Education Plan (IEP)
Copy of most recent Individual Education Plan (IEP) has been provided Yes/No (circle one)
*If No, reason not provided _________________________________________________________________
Documentation to determine eligibility is required according to NSO (Non-School Organisations) guidelines.
Visit Request Form Regional
Issue: 4 May 2010 Page 4 of 4
SCHOOL CONSENT TO VISIT:
I give permission for staff from AQ to visit our school in regard to the above mentioned student.
I confirm that the abovementioned student requires a high level of adjustment.
NSO requires acknowledgement of AQ’s involvement with the abovementioned student in his/her
IEP. I confirm that AQ’s involvement will be recorded on the students IEP and that AQ will be
provided with a copy of this IEP.
I confirm that Autism Queensland has been listed under “Other Agency” on the EAP Consent/ Permission form (N/A to Kindergartens).
Principal’s Name:_________ Principal’s Signature:
Date: _____
Financial contribution for Autism Queensland Outreach Services is provided by the Non School Organisations funding
CURRENT ISSUES/IEP GOALS WANTING TO BE ADDRESSED IN THE VISIT
1.
2.
3.
Relevant Information: Does the child have any co-existing conditions or are there other factors that we should be aware of? If yes, please specify _____________________________________________________
OUTREACH SERVICES
VISIT REQUEST FORM
The Outreach team offers advisory visits to children with a diagnosis of Autism Spectrum Disorder/Asperger syndrome/autism, to schools, pre-schools and kindergartens. Please note that in certain circumstances where there is no educational placement, this service may take place in another setting – please discuss this with the team. These visits provide the opportunity to discuss issues and strategies with our Outreach staff to assist the child’s inclusion into his/her setting. Issues addressed may include behavioural and educational issues, communication, sensory processing, gross and fine motor skills and activities of daily living. Visits are usually 1.5 hours in duration and consist of observation and discussion time.
Following the visit, a written summary will be forwarded to the child’s family and the educational setting in which the visit took place.
VISITS WILL BE SCHEDULED THROUGHOUT THE YEAR ON A NEEDS BASIS
If you would like a visit please complete all sections of the request form below and return it to:
Autism Queensland Inc or Fax: (07) 3273 8306
PO Box 354, Sunnybank, Qld 4109
We will then contact you to arrange an appointment. There is no charge for this service.
If you would like any further information please contact Cathy McNeill on phone (07) 3273 0000
Please note that if form is not completed by all relevant parties and required information not attached, we will be unable to schedule a visit.
Refer to checklist attached to ensure all information is included.
Prior to returning form please check that all sections are completed and relevant information attached.
Copy of IEP (Individual Education Plan) for all children in educational settings
Details of verification and EAP status
Copy of letter of definite diagnosis or Verification of Autism Spectrum Disorder (Education Queensland form 3A) for newly diagnosed or very young children
Any other report or information you may feel will be helpful for our team.
Visit Request Form Regional
Issue: 4 May 2010 Page 2 of 4
CHILD DETAILS
Name:
DOB: School Year Level:
Postal Address:
P/Code:
Phone Number:
Parent/’s name/s:
Parent/’s email address:
Is the child a registered client of Autism Queensland? □ Yes □ No
PARENT/GUARDIAN CONSENT TO VISIT:
I ………….…………….…………………… give permission for relevant documents and information to be released regarding my son/daughter ………………………………….. to Autism Queensland to enable adequate preparation for the visit, to provide eligibility documentation to our funding body (NSO) and for Autism Queensland to discuss my child and share relevant information with his/her support team (e.g. local therapists, teachers) after the AQ visit. A visit summary will be provided to the parent/s /guardian/s and to the education setting in which the visit took place.
Data collected is stored and managed in AQ files and a secure data base according to our Data Management Policy. Please refer to the Autism Queensland Inc Privacy Information and Policies for further information regarding the collection, storage and sharing of information. This is available on our website, www.autismqld.com.au. Alternatively you may request a hard copy by contacting the Outreach Team.
Please tick one box to indicate below whether you give permission for the meeting regarding your child to proceed if you are unable to attend.
I DO give permission for the meeting regarding my child to go ahead if I am unable to attend.
I DO NOT give permission for the meeting regarding my child to go ahead if I am unable to attend.
By signing below I confirm that: I have read and understood the information provided about the outreach visit and the requirements outlined for access to, sharing and storage of information. I have legal custody of the above mentioned child and the legal authority to complete this document. I have provided any relevant custody documentation, where applicable.
Parent/Guardian Signature: Date: _________
SCHOOL DETAILS:
Name of School:
School Email:
Street Address:
P/Code:
Please provide any additional information which may assist us to locate you more easily (e.g. different campuses, parking with different street access etc)
Phone Number:
Fax Number:
Name and position of person requesting visit:
Class Teacher:
Contact Person:
Email:
Visit Request Form Regional
Issue: 4 May 2010 Page 3 of 4
Days and time of child attending:
Preferred times (While every effort is made to accommodate preferred times, these cannot be guaranteed.)
Times Unavailable: (e.g. school excursion etc)
Does the student access a special education service? If so please specify:
Special Education Program, please specify: ______________________ □ Special Education School
Therapy service, please specify: _________________________________ □ AVT service
Other, please specify: ___________________________________________
Please provide details of any other support services accessed by the student (eg. Services provided by non government organisations, private therapists, CYMHS etc):
EVIDENCE OF ELIGIBILITY:
The following information MUST be provided in order for students to be eligible for a visit.
1. Indicate which category applies and attach requested information (Tick ONE box only)
ASD Verification date: ____/____/____
Verified by (circle one): Education Qld/ Catholic Education/ ISQ
Primary verified impairment category (circle one): ASD/II/PI/HI/VI/SE/SLI/other _________
Other verified impairment categories (circle one): ASD/II/PI/HI/VI/SE/SLI/other _________
OR
For younger children or recently diagnosed – copy of letter of definite diagnosis or Verification
of Diagnosis (EQ form 3A)
OR
For students without an EAP:
Ascertainment Category ____________, Level ___________, Date ______________
Reason still ascertained: ___________________________________________________________
AND ___________________________________________________________
2. Individual Education Plan (IEP)
Copy of most recent Individual Education Plan (IEP) has been provided Yes/No (circle one)
*If No, reason not provided _________________________________________________________________
Documentation to determine eligibility is required according to NSO (Non-School Organisations) guidelines.
Visit Request Form Regional
Issue: 4 May 2010 Page 4 of 4
SCHOOL CONSENT TO VISIT:
I give permission for staff from AQ to visit our school in regard to the above mentioned student.
I confirm that the abovementioned student requires a high level of adjustment.
NSO requires acknowledgement of AQ’s involvement with the abovementioned student in his/her
IEP. I confirm that AQ’s involvement will be recorded on the students IEP and that AQ will be
provided with a copy of this IEP.
I confirm that Autism Queensland has been listed under “Other Agency” on the EAP Consent/ Permission form (N/A to Kindergartens).
Principal’s Name:_________ Principal’s Signature:
Date: _____
Financial contribution for Autism Queensland Outreach Services is provided by the Non School Organisations funding
CURRENT ISSUES/IEP GOALS WANTING TO BE ADDRESSED IN THE VISIT
1.
2.
3.
Relevant Information: Does the child have any co-existing conditions or are there other factors that we should be aware of? If yes, please specify _____________________________________________________
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