Child Autism Disorder Clinic - Autism Spectrum Disorder - Child Speech Pathology

Annie's Centre is open from 8am to 7pm Monday to Friday and 8am to 2pm on Saturdays.

centre	283 Avoca St, Randwick NSW, Australia
postal	283 Avoca St, Randwick 2031, NSW, Australia
phone	+ 61 2 9314 5793
fax	+ 61 2 9314 5792
email	info@anniescentre.com

Alternatively, you can complete our online interest form below.

Expression of Interest Form

If you are interested in accessing consultation services at Annie's Centre, in receiving our outreach/ consultation services in your local area, or in participating in any of our workshops, group programs or training courses, then please complete the Expression of Interest Form below.

The information you provide will be used to identify which metropolitan, rural, interstate and overseas locations are in need of our consultation, education and training services. It will assist us in delivering high quality services that meet your specific needs. All the information you provide will be confidential.

After locations in need of our outreach services are identified, we will contact you to inform you of the dates when we are scheduled to be in your local community or communities near you.

The fields marked with an asterisk (*) are mandatory.

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>Title *	>Mr >Mrs >Ms >Miss >Dr
>First Name *	">
>Surname *	">
>Mailing Address *	">
>Suburb *	">
>Postcode *	">
>State *	">
>Country *	">
>Contact phone number *	">
>Email (optional)	">

I have some concerns about my child's development (please tick any that apply):
>	Language and communication skills
>	Play skills
>	Fine and/or gross motor skills
>	Behaviour
>	Attention and organization skills
>	Social skills
>	Literacy and Learning skills
>	Emotional development (e.g., self-esteem, anxiety or depression)

>Please tick one of the following *

>	I am a parent of a child with special health and/or developmental needs
	Age of Child: ">
	Type of school setting (if any)
	">
>	I am a medical or health professional
>	I am an education professional
>	I am an adolescent or adult with special health and/or developmental needs
	Age: ">
>	I am an individual with or I have a child with an Autism Spectrum Disorder
	Age: ">
	Autism spectrum diagnosis:
	>Autistic Disorder
	>Atypical Autism
	>Asperger's Disorder

I wish to express my interest in making an appointment to access consultation services at Annie's Centre (please tick any that apply):
>	Diagnostic and assessment services
>	Educational and/or learning assessments (including IQ assessments)
>	Clinical Psychology services
>	Speech Pathology services
>	Occupational Therapy services
>	Behaviour Therapy and ABA services
>	MULTILIT Reading Tutor Program (Revised)
>	School Based Learning Support services
	Current Group Programs:
>	- Keys to Communication (parents group)
>	- Write On! (Handwriting skills group)
>	- Spot On Kids (Early intervention group for Pre-School aged children)
>	- Busy Babies Playgroup (Early intervention group for babies and toddlers)

I wish to express my interest in receiving outreach/ consultation services in my area:
>	Diagnostic and assessment services
>	School based consultations
>	Educational and/or learning assessments (including IQ assessments)
>	Clinical Psychology services
>	Speech Pathology services
>	Occupational Therapy services
>	Behaviour Therapy and ABA services
>	School Based Learning Support services

I wish to express my interest in attending training at Annie's Centre or having training conducted in my local area:

Group programs:
>	Effective Parenting groups
>	Social skills groups for typically developing children
>	Social skills groups for children with an Autism Spectrum Disorder
>	Anxiety management groups for children
>	Keys to Communication (parents group)
>	Write On! (Handwriting skills group)
>	Spot On Kids (Early intervention group for Pre-School aged children)
>	Busy Babies Playgroup (Early intervention group for babies and toddlers)

Workshops:
>	Assessment and Diagnosis of Autism Spectrum Disorders (for medical and health professionals only)
>	Treating Anxiety in Children with an Autism Spectrum Disorder
>	Managing Challenging Behaviour in Children
>	Learning Support for Children with Autism in the Classroom and at Home
>	Social skills workshops for children with High Functioning Autism and Asperger's
>	Conversation skills workshops for primary school children
>	Study skills workshops for high school students
>	Anxiety management workshops for primary school students

Accredited Training Courses: (for medical and health professionals only)
>	ADOS: Autism Diagnostic Observation Schedule
>	ADI-R: Autism Diagnostic Interview-Revised

I wish to express my interest in purchasing Annie's Centre Publications (please tick any that apply):
>	Annie's Centre Children's Books (coming soon for children, parents and families!)
>	Sensory Processing: A Guide for Parents and Professionals
>	Anxiety Treatment Program for Children with High Functioning Autism and Asperger's (coming soon for clinicians and therapists!)

Any additional coments?
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Thank you for taking the time to complete our expression of interest form. The information you provide will be used to identify which locations are in need of our outreach services. It will assist us in delivering services to these areas.

All the information you provide will be confidential. When locations in need of our outreach services are identified, we will contact you to inform you of the dates we plan to be in your area as well as our Sydney workshop dates.

Child and family health centre specialising in child health, development and education • Annie's Centre • Sydney • Australia

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