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Client Intake Form

Please Note: If you are on our wait list the quickest way to secure an appointment will be to be flexible with days & times as we won’t always have the ideal times available to offer you.

Completing the intake form does not guarantee an appointment; our Speech Pathologists will review the information provided to determine if we are able to provide services to your child based on their needs.

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Your Child’s Information

Client Full Name*

Client Preferred Pronouns*

Client Date of Birth*

DD slash MM slash YYYY

Client Age*

Client Home Address*

Parent / Caregiver / Legal Guardian #1

Full Name*

Relationship to Client*

Mobile Number*

Email Address*

Parent / Caregiver / Legal Guardian #2

Full Name

Relationship to Client

Mobile Number

Email Address

School / Kindergarten / Childcare Details

Institution Type

Name of Institution

Child's Grade (If Applicable)

Teacher/Carer Name

What language is spoken at home?

Is there a family court order in place?*

Yes

Tick all that apply*

Private Health Insurance

Medicare GP Referral (Chronic Disease Management Plan)

National Disability Insurance Scheme (NDIS - select your plan below)

None Of The Above

If you selected NDIS, what applies to you?*

Please note we do NOT provide services to NDIA / Agency Managed NDIS clients.

Self Managed

Plan Managed

Not Applicable

Who referred you?

Main concerns or reason for referral

Client Questionnaire

1. Does your child have any diagnosis we should be aware of?*

2. What is your child's preferred method of communication?*

For example: Gestures, Mouthed or Non-mouthed Communication etc.

3. Are you or anyone else concerned about the child’s ability to say specific speech sounds?*

Yes

4. Are you or anyone else concerned about the child’s ability to be understood by others?*

Yes

5. Are you or anyone else concerned about the child’s ability to follow instructions?*

Yes

6. Are you or anyone else concerned about the child’s ability to understand, follow, or keep up with conversations?*

Yes

7. Have you or anyone else noticed differences in the way the child plays with a range of toys or engages in a range of activities?*

Yes

8. Have you or anyone else noticed differences in the way the child plays with peers?*

Yes

9. Are you or anyone else concerned about the child’s ability to read, spell, or understand written text?*

Yes

10. Have you or anyone else noticed differences in the child’s behaviour?*

Yes

11. Are you or anyone else concerned about the child’s stuttering or inability to speak fluently?*

Yes

12. Is or has the child been involved with any other health professionals? If so, please select the relevant option and list their info below in the following section.

Paediatrician

Psychologist

Occupational Therapist

Audiologist

Optometrist

Ear, Nose and Throat Specialist

Orthodontist

Chiropractor

Physiotherapist

Other:

Other

13. Has the child seen a Speech Pathologist before?*

Yes

14. Would you like to place your child on our cancellation List?*

If yes, please let us know your preferred days and times during the week. For example: If a client is unable to attend their appointment last minute we can offer this appointment time to yourself.

Please select your preferred delivery mode?*

Online Therapy (via Zoom) - Appointments Available Immediately!

Clinic Visits - Join Waitlist (Deer Park, VIC)

Clinic Visits - Join Waitlist (Brunswick, VIC)

No Preference

Additional comments or message?

Privacy Disclaimer*

By providing us with this Personal Sensitive Information, you acknowledge and agree that the information you are providing to us is true and correct at the time you are providing it to us. You will notify us with any changes and keep it updated on a regular basis while you are using our Services. You can access the Personal Sensitive Information by request at any time. We keep all Personal Sensitive Information secure and do not use it for any purposes unrelated to our Services. All our employees and any staff who may have access this personal information are under a strict duty of confidentiality and privacy practices are adhered to. Please note: we securely destroy all Personal Sensitive Information after seven years if you have ceased using our Services. From time to time, we may use your Personal Sensitive Information to contact you in relation to information on our Services. You can unsubscribe at any time or advise us that you withdraw your consent to these specific uses and be removed from any further marketing or information we may send.

I have read and understood the Privacy Disclaimer

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Book an Appointment

Client Intake Form

Your Child’s Information

Parent / Caregiver / Legal Guardian #1

Parent / Caregiver / Legal Guardian #2

School / Kindergarten / Childcare Details

Client Questionnaire

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Email Us

Our Address

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