Registration form for FASD Australia Service Directory

Health professionals (medical and allied health) can register to be included on the FASD Hub Australia Service Directory.

We are seeking health professionals who have experience contributing to a FASD diagnosis or have provided therapy and/or support to a person diagnosed with FASD and their family.

I am registering... *

a clinic, service or practice

an individual health professional

Choose whichever is most applicable. (If you wish to complete registration as both a clinic and individual health professional you will be prompted at the end to complete for the second option).

Clinic, Service or Practice

Please include the information you would like to appear on the FASD Hub Australia Service Directory

Name of clinic, service or practice (if relevant)

Name of contact person *

Address *

Address 2

City/Town *

State/Territory *

Postcode *

Email Address *

Phone Number *

Website

What is the nature of your clinic, service or practice? *

FASD assessment clinic

Hospital outpatient service

Child development unit/service

Private practice

All options

Other (please specify)

Please indicate which health professionals are available at your clinic, service or practice *

Paediatrician

Psychiatrist

Neurologist

Neonatalogist

Geneticist

Clinical Psychologist

Neuropsychologist

Speech Pathologist

Occupational Therapist

Physiotherapist

Social Worker

Indigenous Health Worker

Child Health Nurse

Obstetrician

Midwife

Other (please specify)

Psychologist

If you would like to include information on health professionals in your practice, please include their name and area of expertise eg. Dr Julie Smith, Paediatrician

What type of service is provided at your clinic or practice? *

Assessment

Initial management

Ongoing management

All options

Other (please specify)

Who will your clinic, service or practice accept referrals from? *

General Practitioners

Paediatricians

Other medical specialists

Psychologists

Allied health professionals

Families

Child protection services

Education Departments

Justice Departments

All options

How do you bill at your clinic, service or practice? *

Medicare bulk-billed

Medicare plus additional fee

Fee - advised when person contacts the clinic, service or practice

Other (please specify)

What is the age/s of people you assess, treat or provide support for? *

0 - 4 years

5 - 11 years

12 - 18 years

Adults (> 18 years)

All options

Other (if other age categories apply please add details)

Please describe your clinic's experience in contributing to the FASD assessment and diagnostic process, or providing support and/or therapy to a person with FASD and their family. Please indicate whether your clinic has completed any FASD specific education or training (online or face-to-face). *

Would you like to subscribe for the FASD Hub quarterly e-newsletter? *

Yes

Do you also wish to complete registration as an individual health professional? *

Yes

Individual Health Professional

Please include the information you would like to appear on the FASD Hub Service Directory

Your name *

Address *

Address 2

City/Town *

State/Territory *

Postcode *

Email Address *

Phone Number *

Website

Please indicate your area of professional expertise *

Paediatrician

Psychiatrist

Neurologist

Neonatologist

Geneticist

Clinical Psychologist

Neuropsychologist

Psychologist

Speech Pathologist

Occupational Therapist

Social Worker

Physiotherapist

Obstectrician

Midwife

Indigenous Health Worker

Child Health Nurse

Other

Who will you accept referrals from? *

General Practitioners

Paediatricians

Other medical specialists

Psychologists

Allied health professionals

Families

Child protection services

Education Departments

Justice Departments

All options

What is the age/s of people assessed or services provided for? *

0 - 4 years

5 - 11 years

12 - 18 years

Adults (> 18 years)

All options

Other

How do you bill? *

Medicare bulk-billed

Medicare plus additional fee

Fee - advised when person contacts the clinic, service or practice

Other (please specify)

Please describe your experience in contributing to the FASD assessment and diagnostic process, or providing therapy and/or support to a person with FASD and their family. Please indicate whether you have received any FASD specific education or training (online or face-to-face). *

Help me choose

FASD Information

Training & Support

Research & Publications

Registration for the FASD Hub Australia Service Directory

Clinic, Service or Practice

Individual Health Professional