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Key Worker Service
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- FAQ
  - QUESTIONS ABOUT SPEECH PATHOLOGY SERVICES
  - GENERAL QUESTIONS ABOUT OUR CLINIC
- INFORMATION FOR CAREGIVERS AND REFERRERS
  - School Age Children
  - Pre-School Age Children
Workshops & Training
Careers
Clinical Supervision
Contact
ONLINE referral form

Home
ABOUT THRIVE
Key Worker Service
Meet The Team
FAQ & OTHER INFORMATION
- FAQ
  - QUESTIONS ABOUT SPEECH PATHOLOGY SERVICES
  - GENERAL QUESTIONS ABOUT OUR CLINIC
- INFORMATION FOR CAREGIVERS AND REFERRERS
  - School Age Children
  - Pre-School Age Children
Workshops & Training
Careers
Clinical Supervision
Contact
ONLINE referral form

REFERRING YOUR CHILD TO SPEECH PATHOLOGY

CLIENT REFERRAL FORM

Please fill in the details below, and we will be in touch about adding your child to our waiting list.

Please enable JavaScript in your browser to complete this form.

Name *

First

Last

Preferred Pronouns

If Other

Date of birth *

Child's age *

Home address *

School details

First

Middle

Last

Or Kinder name

Or Childcare name

What language is spoken at home?

Parent / Caregiver / Legal guardian #1 *

First

Last

Preferred Pronouns *

If Other *

Phone & Email *

First

Last

Parent / Caregiver / Legal guardian #2

First

Last

Preferred Pronouns *

If Other *

Phone & Email

First

Last

Is the child of Aboriginal or Torres Strait Islander origin? *

No
Yes, Aboriginal
Yes, Torres Strait Islander
Yes, both Aboriginal and Torres Strait Islander

Is there a family court order in place? *

Tick all that apply

Private Health Insurance
Medicare (Chronic Disease Management Plan) Referral
National Disability Insurance Scheme (NDIS - select your plan below)

If you ticked NDIS, what applies to you?

Self-managed
Plan managed

Please note that our clinic is not registered to provide services to Agency Managed NDIS Participants

Who referred you?

Main Concerns

If your child is seeing multiple therapists, you may be interested in our Key Worker Service.

Do you want to be considered for our Key Worker Service? *

You might qualify for an earlier appointment if your child is suitable for our Allied Health Assistant Program. You can read about our Allied health Assistant Program here.

Do you want to be considered for the Allied Health Assistant (AHA) Program? *

Reason for Referral

Please tick any of the following that apply. I have noticed and/or someone else has noticed differences/difficulties in the way that the child:

Says speech sounds
Is understood by others
Follows directions
Understands or keeps up with conversations
Joins groups
Makes and maintains friendships with peers
Plays with a range of toys or engages in a range of activities
Plays with peers
Reads, spells, or understands written text
Expresses their emotions
Initiates and maintains attention and focus
Speaks fluently

Please provide any further information below:

Is or has the child been involved with any other health professionals?

Paediatrician
Audiologist
Orthodontist
Psychologist
Optometrist
Chiropractor
Occupational Therapist
Ear Nose and Throat Specialist
Physiotherapist
Other

If so, please list their name and contact information, and upload any relevant reports.

1st Healthcare Professional

Health Professional name

Name of practice

Phone number

Email address

2nd Healthcare Professional

Health Professional name

Name of practice

Phone number

Email address

3rd Healthcare Professional

Health Professional name

Name of practice

Phone number

Email address

15. Has the child seen a Speech Pathologist before? If yes, please submit all relevant reports. *

Upload file/s:

Click or drag a file to this area to upload.

Tick which service delivery you are wanting: *

Telehealth (via Zoom)
Clinic Visits (subject to State Legislated COVID-19 Restrictions)
No preference

Additional comments or message?

I have read and understood the following policies: *

Personal and Health Information Collection Statement for Minors, Disclaimer, terms and Conditions

You can view these policies in the footer of this website.

WE LOOK FORWARD TO WELCOMING YOU TO OUR CLINIC

CONTACT OUR CLINIC

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CONTACT

03 9746 2057
03 9005 2826
hello@thrivechildrenstherapy.com.au
222 Mitchells Lane, Sunbury VIC 3429

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Online Referral Form
Speech Pathologist
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