How did you hear about us? Please select Advertisement Article/News Event/Conference Google Search Social Media Web Forum Word of Mouth Other

Do you have a fast internet connection e.g. can you watch programmes on iPlayer? Yes No Unsure

What is your child’s primary communication method? Please select Verbal Written Signs/gestures Picture/symbol exchange None

What is your child's date of birth? 

Does your child engage in a behaviour that is deemed extremely harmful or dangerous (which could cause serious injury to themselves or others)? Yes No

Has your child been diagnosed as “clinically depressed” and/or has had thoughts of suicide? Yes No

Who is going to deliver the programme? We recommend a minimum of 15 hours per week of your time, but this is dependent on the level of the support package. Please select Myself (parent or carer) Another family member or carer Myself and another family member or carer I/we are not sure we have time to deliver the programme I want a Beam clinician to deliver the programme in my home

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