Therapy Provisions During School Hours Form

Requirements for Therapists

• Provide a copy of your Working with Children Check and DOE Police Clearance.
• Provide a current Therapy Plan which clearly outlines the therapy that will be provided and meets one of the school’s four on site Therapy Priorities.
• Follow the Department of Education’s ‘Visitors and Intruders on School Premises Policy’ and sign in on the iPad (located in the administration building) before and after each therapy session.
• Sign the Individual Therapy Student Record (located in the classroom) after each therapy session.
• Wear your identification sticker (generated from the iPad sign in).
• Provide staff training and written/photographic documentation describing any procedures that the school agrees will be undertaken by staff.

Therapy Provisions During School Hours Online Form

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STUDENT DETAILS *

First

Last

Name of Student

Parent/Guardian Name *

First

Last

Contact Phone Number *

Email *

Role of Parent/Guardian *

• Parent
• Carer
• Case Manager (CPFS)
• Other

If selecting other please specify

*Are you authorised to make this request? (Please select) Yes/No *

• Yes
• No

REQUESTED LOCATION FOR THERAPY/SERVICE DURING SCHOOL HOURS *

• School
• A location other than school during school hours

If selecting school choose one of the following locations *

• Classroom
• To be negotiated with class teacher
• Other

If selecting other please specify

If selecting location other than school choose one of the following locations *

• Home
• Venue contact number
• Other

See Form B

If selecting other please specify

PLEASE SELECT THE FOLLOWING OPTIONS FOR APPROVAL *

• I will notify the school in writing should these details change.
• I understand that I will be notified if this application is approved.

one THERAPY/SERVICE make

Signature *

Clear Signature

Date *

Submit