Name *

First Name

Last Name

Address (needed to add your child to our waiting list)

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Days available

Please note we currently only have availability during school hours Wednesday (Torquay-Medical Play Therapy) and Thursdays (Ocean Grove) during school hours in 2024.

Thursday (in school hours)- Ocean Grove

Wednesday (in school hours) Torquay - Medical Play Therapy

None of the above

Current concerns - diagnoses for your child

Autism or Other Neurodivergence

ADHD or Other Neurodivergence

Behavioural Concerns or Emotional Regulation Difficulties

Anxiety or Separation Anxiety

Trauma Related Difficulties or Those Related to Out of Home Care

Attachment Related Difficulties

School Related Difficulties or Dyslexia/Dyspraxia Related Difficulties

Recent Family Disruption (separation, divorce, moving home etc)

Grief, Loss or Bereavement

Medical Trauma

Chronic Illness

Needle Fear

Low Self Esteem or Negative Self Belief

Sleeping, Toileting or Eating Difficulties

Concerns About a Family Member (parental mental illness, sibling illness etc).

Impacts from a Natural Disaster or Traumatic Incident

Sensory needs re. medical preparation

Other therapists involved

OT

Speech

Psychology

Behavioural Support

Physio

Paediatrician

GP

Nurse

Nutrition/Dietitian

School Support

Other