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Modern Medical | Suite C3A 1042 Western Highway, Caroline Springs, VIC - 3023
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Client Intake Form
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Step
1
of
5
20%
Your Child’s Information
Client Full Name
*
Client Preferred Pronouns
*
Response
He/Him
She/Her
Other
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
Response
School
Kindergarten
Childcare
Other
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
No
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
No
4. Are you or anyone else concerned about the child’s ability to be understood by others?
*
Yes
No
5. Are you or anyone else concerned about the child’s ability to follow instructions?
*
Yes
No
6. Are you or anyone else concerned about the child’s ability to understand, follow, or keep up with conversations?
*
Yes
No
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
No
8. Have you or anyone else noticed differences in the way the child plays with peers?
*
Yes
No
9. Are you or anyone else concerned about the child’s ability to read, spell, or understand written text?
*
Yes
No
10. Have you or anyone else noticed differences in the child’s behaviour?
*
Yes
No
11. Are you or anyone else concerned about the child’s stuttering or inability to speak fluently?
*
Yes
No
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
No
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 the format of service delivery you prefer
Telehealth (via Zoom)
Clinic Visits (subject to State Legislated COVID-19 Restrictions)
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.
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Phone Number
0402 332 425
Email Address
admin@aspeechie.com
Our Address
Modern Medical | Suite C3A 1042 Western Highway, Caroline Springs, VIC - 3023
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