New Registration Form

This form is comprehensive, so we don't have to send you form after form to gather all the information and consent we need. Once you fill this out, it will be reviewed, and once approved, it will form the basis for the Service Agreement. This will be mostly filled out, so you just have to read and sign! Please allow up to a week to receive a response.

New Participant Registration Form

For all new attendees at Peppermint Place

Step 1 of 5 - Personal Details

20%

Your Name (Parent/Guardian)(Required)

First Last

Phone(Required)

Email(Required)

Address(Required)

Street Address Suburb Postcode

Participant's Name(Required)

First Last

Relationship To Particpant

Mother, Father, Grandparent, Guardian etc

Participant's Date of Birth(Required)

DD slash MM slash YYYY

Participant's Birth Gender(Required)

Male

Female

Participant's NDIS Number(Required)

NDIS Plan Start Date(Required)

MM slash DD slash YYYY

NDIS Plan End Date(Required)

MM slash DD slash YYYY

Emergency Contact Name(Required)

Who would you like us to contact if you are unreachable?

First Last

Emergency Contact Phone Number(Required)

Funding Management Type(Required)

NDIS Managed

Plan Managed

Self Managed

Self Funding (No NDIS Funding)

Email Address for Invoices(Required)

Plan Manager Name(Required)

Plan Manager Organisation

Plan Manager Invoice Email(Required)

Plan Manager Phone(Required)

Participants Current Goals(Required)

Please provide a brief summary of their skills, social and communication goals.

Which Program Are Registering Your Child/Young Person For?(Required)

After School Skills Program (School Pick Up - 6 pm)

Holiday Intensive Skills Program (8:30 am - 3:30 pm)

Adult Day Skills Program (9 am - 2 pm)

Days of Attendance Odd School Weeks (weeks 1, 3 ,5 etc)(Required)

(Select All That Apply)

Monday

Tuesday

Wednesday

Thursday

Friday

Days of Attendance Even School Weeks (weeks 2, 4, 6 etc)(Required)

(Select All That Apply)

Monday

Tuesday

Wednesday

Thursday

Friday

Day/s of Attendance(Required)

Monday

Tuesday

Wednesday

Thursday

Friday

Preferred Start Date(Required)

DD slash MM slash YYYY

Dates of Attendance Week 1

Select up to 3 choices.

Monday 13th July

Tuesday 14th July

Wednesday 15th July

Thursday 16th July

Friday 17th July

Dates of Attendance Week 2

Select up to 3 choices.

Monday 20th July

Tuesday 21st July

Wednesday 22nd July

Thursday 23rd July

Friday 24th July

Additional Days(Required)

We currently limit this program to 3 days, but if we have space, we have a waiting list, so more days may be possible for you. Do you want to go on the waiting list?

Yes

Dates of Attendance Week 1

Select up to 2 choices.

Monday 13th July

Tuesday 14th July

Wednesday 15th July

Thursday 16th July

Friday 17th July

Dates of Attendance Week 2

Select up to 2 choices.

Monday 20th July

Tuesday 21st July

Wednesday 22nd July

Thursday 23rd July

Friday 24th July

Ratio of Support(Required)

Please indicate your preference. This may be changed based on a number of factors including: medical, self care, behavioural, and safety needs.

1:3

1:2

1:1

Unsure

Medication Requirements

Will medication (including over-the-counter) be required to be administered during program hours?

Yes

DECLARATION(Required)

I consent to the following medication being administered (as per the instructions on the pharmacy label and/or any additional written instructions) to the participant named above during Peppermint Place attendance.

I authorise Peppermint Place staff to contact the prescribing health practitioner or pharmacist (as listed on the medication's pharmacy label or in other relevant medical authorisation) for the purpose of seeking specific advice or clarification on the administration of this medication to this participant.

1st Medication(Required)

Please add the name of the most important medication your child needs.

1st Medication Frequency(Required)

How often is this medication required?

Routinely Ongoing (e.g. 11am every day)

Temporarily Routinely (for a short time eg: antibiotics for 2 weeks)

As Needed (e.g. to treat minor or non-emergency symptoms like pain)

Routine Ongoing Instructions:(Required)

Administer at; (e.g. 3pm every Monday/Wednesday/Friday etc.)

Temporarily Routine Instructions:(Required)

Administer for how long and when (e.g. 2 weeks, with lunch)

As Needed Instructions:(Required)

Administer under what conditions and dosage (e.g. when in pain, as listed on the label)

As Needed Medication Declaration(Required)

I understand that before Peppermint Place administers this medication, if they are not aware of when this medication was most recently given to the participant, I will be contacted to provide this information.

Ability to Self-Administer (Over 18 only)

Will your young person be self-administering this medication? This means they will be FULLY responsible for knowing when and how to give it to themselves, and also know what the limits in dose and timing are.

Yes

Permission To Self-Administer This Medication(Required)

Please check all boxes to confirm your agreement and understanding:

I confirm that your young person is confident, competent and can safely administer the right dose of their own medication at the right times.

I confirm that your young person can store their medication safely.

I confirm that your young person is fully aware of the limitations in dosage and timing required for safely taking this medication.

I authorise Peppermint Place staff to contact the prescribing health practitioner, health team or pharmacist (as listed on the medication's pharmacy label or in other relevant medical authorisation) for the purpose of seeking specific advice or clarification on the administration of this medication by your young person.

Purpose of Medication(Required)

Is this medication used to manage a health condition by following a current action plan or health plan?

Yes

Linked Medical Condition(Required)

Is this medication used to manage a health condition by following a current action plan or health plan?

ADHD

Anxiety

Asthma

Anaphylaxis

Cystic Fibrosis

Diabetes

Epilepsy

Other

Other Health Plan Information(Required)

Please tell us what action or health plan this medication is for:

Side Effects

Has your child exhibited any side effects from this medication?

Yes

Side Effect Symptoms(Required)

Please describe the symptoms, severity and timeline:

Is there a 2nd Medication?(Required)

Prescription or Over-The-Counter

Yes

2nd Medication(Required)

Please add the name of the next most important medication your child needs.

2nd Medication Frequency(Required)

How often is this medication required?

Routinely Ongoing (e.g. 11am every day)

Temporarily Routinely (for a short time eg: antibiotics for 2 weeks)

As Needed (e.g. to treat minor or non-emergency symptoms like pain)

Routine Ongoing Instructions:(Required)

Administer at; (e.g. 3pm every Monday/Wednesday/Friday etc.)

Temporarily Routine Instructions:(Required)

Administer for how long and when (e.g. 2 weeks, with lunch)

As Needed Instructions:(Required)

Administer under what conditions and dosage (e.g. when in pain, as listed on the label)

As Needed Medication Declaration(Required)

I understand that before Peppermint Place can administer this medication, they need to be aware of when this medication was most recently given to the participant. If this information has not been given, I understand I will be contacted to provide this information BEFORE the medication is administered.

Ability to Self-Administer (Over 18 only)(Required)

Yes

Permission To Self-Administer This Medication(Required)

Please check all boxes to confirm your agreement and understanding:

I confirm that your young person is confident, competent and can safely administer the right dose of their own medication at the right times.

I confirm that your young person can store their medication safely.

I confirm that your young person is fully aware of the limitations in dosage and timing required for safely taking this medication.

Purpose of Medication(Required)

Is this medication used to manage a health condition by following a current action plan or health plan?

Yes

Linked Medical Condition(Required)

Is this medication used to manage a health condition by following a current action plan or health plan?

ADHD

Anxiety

Asthma

Anaphylaxis

Cystic Fibrosis

Diabetes

Epilepsy

Other

Other Health Plan Information(Required)

Please tell us what action or health plan this medication is for:

Side Effects

Has your child exhibited any side effects from this medication?

Yes

Side Effect Symptoms(Required)

Please describe the symptoms, severity and timeline:

Is there a 3rd Medication?(Required)

Prescription or Over-The-Counter

Yes

3rd Medication(Required)

Please add the name of the next most important medication your child needs.

3rd Medication Frequency(Required)

How often is this medication required?

Routinely Ongoing (e.g. 11am every day)

Temporarily Routinely (for a short time eg: antibiotics for 2 weeks)

As Needed (e.g. to treat minor or non-emergency symptoms like pain)

Routine Ongoing Instructions:(Required)

Administer at; (e.g. 3pm every Monday/Wednesday/Friday etc.)

Temporarily Routine Instructions:(Required)

Administer for how long and when (e.g. 2 weeks, with lunch)

As Needed Instructions:(Required)

Administer under what conditions and dosage (e.g. when in pain, as listed on the label)

As Needed Medication Declaration(Required)

Ability to Self-Administer (Over 18 only)(Required)

Yes

Permission To Self-Administer This Medication(Required)

Please check all boxes to confirm your agreement and understanding:

I confirm that your young person is confident, competent and can safely administer the right dose of their own medication at the right times.

I confirm that your young person can store their medication safely.

I confirm that your young person is fully aware of the limitations in dosage and timing required for safely taking this medication.

Purpose of Medication(Required)

Is this medication used to manage a health condition by following a current action plan or health plan?

Yes

Linked Medical Condition(Required)

Is this medication used to manage a health condition by following a current action plan or health plan?

ADHD

Anxiety

Asthma

Anaphylaxis

Cystic Fibrosis

Diabetes

Epilepsy

Other

Other Health Plan Information(Required)

Please tell us what action or health plan this medication is for:

Side Effects

Has your child exhibited any side effects from this medication?

Yes

Side Effect Symptoms(Required)

Please describe the symptoms, severity and timeline:

Is there a 4th Medication?(Required)

Prescription or Over-The-Counter

Yes

4th Medication(Required)

Please add the name of the next most important medication your child needs.

4th Medication Frequency(Required)

How often is this medication required?

Routinely Ongoing (e.g. 11am every day)

Temporarily Routinely (for a short time eg: antibiotics for 2 weeks)

As Needed (e.g. to treat minor or non-emergency symptoms like pain)

Routine Ongoing Instructions:(Required)

Administer at; (e.g. 3pm every Monday/Wednesday/Friday etc.)

Temporarily Routine Instructions:(Required)

Administer for how long and when (e.g. 2 weeks, with lunch)

As Needed Instructions:(Required)

Administer under what conditions and dosage (e.g. when in pain, as listed on the label)

As Needed Medication Declaration(Required)

Ability to Self-Administer (Over 18 only)(Required)

Yes

Permission To Self-Administer This Medication(Required)

Please check all boxes to confirm your agreement and understanding:

I confirm that your young person is confident, competent and can safely administer the right dose of their own medication at the right times.

I confirm that your young person can store their medication safely.

I confirm that your young person is fully aware of the limitations in dosage and timing required for safely taking this medication.

Purpose of Medication(Required)

Is this medication used to manage a health condition by following a current action plan or health plan?

Yes

Linked Medical Condition(Required)

Is this medication used to manage a health condition by following a current action plan or health plan?

ADHD

Anxiety

Asthma

Anaphylaxis

Cystic Fibrosis

Diabetes

Epilepsy

Other

Other Health Plan Information(Required)

Please tell us what action or health plan this medication is for:

Side Effects

Has your child exhibited any side effects from this medication?

Yes

Side Effect Symptoms(Required)

Please describe the symptoms, severity and timeline:

Is there a 5th Medication?(Required)

Prescription or Over-The-Counter

Yes

5th Medication(Required)

Please add the name of the next most important medication your child needs.

5th Medication Frequency(Required)

How often is this medication required?

Routinely Ongoing (e.g. 11am every day)

Temporarily Routinely (for a short time eg: antibiotics for 2 weeks)

As Needed (e.g. to treat minor or non-emergency symptoms like pain)

Routine Ongoing Instructions:(Required)

Administer at; (e.g. 3pm every Monday/Wednesday/Friday etc.)

Temporarily Routine Instructions:(Required)

Administer for how long and when (e.g. 2 weeks, with lunch)

As Needed Instructions:(Required)

Administer under what conditions and dosage (e.g. when in pain, as listed on the label)

As Needed Medication Declaration(Required)

Ability to Self-Administer (Over 18 only)(Required)

Yes

Permission To Self-Administer This Medication(Required)

Please check all boxes to confirm your agreement and understanding:

I confirm that your young person is confident, competent and can safely administer the right dose of their own medication at the right times.

I confirm that your young person can store their medication safely.

I confirm that your young person is fully aware of the limitations in dosage and timing required for safely taking this medication.

Purpose of Medication(Required)

Is this medication used to manage a health condition by following a current action plan or health plan?

Yes

Linked Medical Condition(Required)

Is this medication used to manage a health condition by following a current action plan or health plan?

ADHD

Anxiety

Asthma

Anaphylaxis

Cystic Fibrosis

Diabetes

Epilepsy

Other

Other Health Plan Information(Required)

Please tell us what action or health plan this medication is for:

Medical Requirements:(Required)

Please confirm that each medication provided to Peppermint Place:

Is medically authorised/recommended (e.g. has been prescribed by a doctor, dentist, optometrist or nurse practitioner)

Is in the original dispensed container with intact packaging

(For Prescribed Medications) Has the participant's and doctor's names on the pharmacy label (if there is no other written evidence of medical authorisation)

(For Over The Counter Medications) Has the participant's name on a pharmacy label on the medication with dosage and frequency recommendations

Is current/in-date

Health Plans

Do you have any health management plans for your young person, such as how to manage their anaphylaxis, asthma or epilepsy?

Yes

Waiting for one to be done

Health Plan Upload(Required)

Please upload your health management plans, one at a time:

Drop files here or

Max. file size: 128 MB.

Has your female young person started their menstrual cycles?(Required)

Yes

Menstrual Assistance Requirements(Required)

For young females who have started their menstrual cycles, please indication what assistance they require:

Needs help physically changing pads /period underwear regularly and managing the extra hygiene associated

Needs to be reminded to change her pads/period underwear

Toileting Assistance(Required)

Does your young person require help with toileting (including those who are still in nappies)?

Yes

Assistance Requirements(Required)

How much assistance does your young person need?

Still in nappies, requires full assistance

Moderate physical assistance such as wiping properly, clothing and reminders to go

Limited, generally only needs prompting and occasional assistance

No assistance needed at all

Structured Toileting Routine(Required)

Does your young person have a set routine for when they should be promoted to go to the toilet?

Yes

Toileting Routine(Required)

Please describe the times or events that your young person should be prompted to go to the toilet (e.g. 10am or after lunch etc):

Additional Assistance Requirements(Required)

Please tick anything below that your young person also requires assistance with:

Hand washing

Knowing when to add or remove clothing to adjust to temperature

Putting clothes on or taking them off

Knowing when to eat or drink

Making decisions

With self-regulation

GETTING TO KNOW YOUR YOUNG PERSON

Things I Love(Required)

Please tell us about what brings your young person joy, to do, be around, to be in their environment:

Things I Don't Like(Required)

Please tell us about what can be triggering to your young person, things they avoid, that upset or frustrate them:

Things I Struggle With(Required)

Please tell us about what things your young person struggles with, such as social connection, communication, fine motor skills, emotional regulation etc:

Signs I'm Struggling(Required)

Please tell us about what behaviours or signs we can see when they are starting to struggle or get dysregulated:

Ways To Help Your Young Person(Required)

Please tell us what strategies, tools or sensory items help them to feel safe and calm:

Dysregulation Behaviours(Required)

Please indicate which behaviours your young person exhibits that we need to be aware of (NB: Ticking any of these does not mean they won't be accepted, it just means we're prepared):

Aggressive towards other

Aggressive towards self

Destructive to objects, furniture their environment

Screams loud

Head bangs

Flops

Retreats/shuts down

Runs away

Other

Other Dysregulation Behaviours

Please add any additional behaviours that are not listed above:

Positive Behaviour Support Plan(Required)

Does your young person have a Positive Behaviour Support Plan in place?

Yes

Currently In Process

Positive Behaviour Support Plan Upload(Required)

Please upload your latest plan so we can be informed and prepared to support your young person:

Max. file size: 128 MB.

Additional Reports Upload

If you have any therapist reports such as recent speech or occupational therapy reports, please upload so we are informed and prepared to support them as best we can:

Drop files here or

Max. file size: 128 MB.

CAPTCHA

Still Have Questions?

If you have questions about whether or not Peppermint Place is a good fit for your child/young adult, or regarding your NDIS package and how it could be used for one of our programs, please fill out the form and a lovely human being will contact you.

Send an Enquiry

New Registration Form

New Participant Registration Form

GETTING TO KNOW YOUR YOUNG PERSON

Still Have Questions?

Explore Our Programs

Connect With Us

Quick Links

Success!