Feeling is Thinking - Intake Form

Thank you for your interest in the Feeling is Thinking group program.

To get started simply fill on the form below. Please note that all fields marked with an asterisk (*) require an answer to continue.

When: Monday afternoon for 8 weeks, starting 28th July 2025

Time: 4:00pm - 5:30pm (All Sessions)

Where: Bridgewood Primary School & Child & Family Centre 115 Bridge Rd, Officer 3809

Cost: There is no cost involved

RSVP: Confirmation of enrolment/eligibility for the program will be evaluated in collaboration with the program facilitator and parent/carer via phone call prior to the program commencement.

If you have any enquiries about the program, please send an email to IFSGroups@windermere.org.au or call us on 1300 946 337

Thank you for your interest in the Feeling is Thinking group program.

To get started simply fill on the form below. Please note that all fields marked with an asterisk (*) require an answer to continue.

Child Participant Details

Given Name(s) *

Surname *

Date of birth *

Gender

Other:

Aboriginal or Torres Straight Islander? *

Interpreter needed? *

YesNo

Country of Birth *

Preferred language *

Address: *

Parent/Carer Details

Please list the number of parents / carers filling in this form: *

12

Parent/Carer 1's Given Name(s): *

Parent/Carer 1's Surname: *

Mobile: *

Work Number:

Email address: *

Interpreter Needed? *

YesNo

Preferred language: *

Would you like to receive information about future Windermere programs via email? *

YesNo

Parent/Carer 2's Given Name(s): *

Parent/Carer 2's Surname: *

Mobile: *

Work number:

Email address: *

Interpreter Needed? *

YesNo

Preferred language: *

Would you like to receive information about future Windermere programs via email? *

YesNo

Additional Information

Do you, or your child require any additional supports or adjustments due to disability, illness, or mental health condition? *

YesNo

Please describe below: *

Are there any existing court orders, parental orders, or intervention order documents? *

YesNo

Please specify: *

Has your child received counselling or any psychological treatment? *

YesNo

Is there any current or historical family violence? *

YesNo

Is there a safety plan in place? *

YesNo

Please list up to three of the most significant difficulties the child is having: *

How do you believe this group will benefit this child? What outcomes would you like to see for the child at the end of the group? *

How did you find out about this program?

Please specify:

Emergency Contact:

Full Name: *

Phone number: *

Relationship to Participant: *

Medical Information

Does your child have any allergies? *

YesNo

If yes, please describe if the condition requires any additional support: *

Does your child have any medical conditions? *

YesNo

Please describe if condition requires any additional support: *

Is your child taking any medications? *

YesNo

Please list all of the medications: **Note: medication will need to be carried on child if required at time of program and be administered by child

Can your child take these medications without assistance? *

YesNo

Please describe what assistance is required: *

Privacy Statement & Consent

Windermere will

collect, use and store your personal information, including health information, in order to provide services to you and/or your family
use your email address (where provided) to send you information that may be of interest to you as identified by your worker. Every communication will provide you with an opportunity to opt out. You can also opt out by contacting your worker or by emailing us at info@windermere.org.au.
not use your personal information for any other purpose without your prior consent or allowed or required by law
comply with the Privacy Act 1998 (Cth), as amended from time to time and the Health Records Act 2001 (Vic)
ensure that all personal information obtained about you will be appropriately collected, used, disclosed and transferred and will be stored safely and protected against loss, unauthorised access, use, modification or disclosure and any other misuse
use information (that does not identify you) for the purposes of research, reporting and improvement; and
in accordance with its privacy policy and the relevant privacy legislation, not disclose your personal information to others without your consent (see Release of Information form)

You have a right to request access to your client record containing your personal information and may make a request to correct/update personal information at any time. Any request to access or update your client record must be made in writing to the Privacy Officer.

When releasing information to others, Windermere will only share information that is necessary in order to provide the services that are of benefit to you, or as otherwise required by law.

For more information please see our Privacy Policy.

I have read and agree to Windermere's Privacy Policy *

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