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.

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Name
School details
Parent / Caregiver / Legal guardian #1
Phone & Email
Parent / Caregiver / Legal guardian #2
Phone & Email
Is there a family court order in place?
Tick all that apply
If you ticked NDIS, what applies to you?
Please note that our clinic is not registered to provide services to Agency Managed NDIS Participants
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
1. Are you or anyone else concerned about the child’s ability to say specific speech sounds?
2. Are you or anyone else concerned about the child’s ability to be understood by others?
3. Are you or anyone else concerned about the child’s ability to follow instructions?
4. Are you or anyone else concerned about the child’s ability to understand, follow, or keep up with conversations?
5. Have you or anyone else noticed differences in the way the child joins groups?
6. Have you or anyone else noticed differences in the way the child makes and maintains friendships with peers?
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?
8. Have you or anyone else noticed differences in the way the child plays with peers?
9. Are you or anyone else concerned about the child’s ability to read, spell, or understand written text?
10. Have you or anyone else noticed differences in the child’s behaviour?
11. Have you or anyone else noticed differences in the child’s attention and focus?
13. Are you or anyone else concerned about the child’s stuttering or inability to speak fluently?
14. Is or has the child been involved with any other health professionals?
If so, please list their name and contact information, and upload any relevant reports.
15. Has the child seen a Speech Pathologist before? If yes, please submit all relevant reports.
Click or drag a file to this area to upload.
Tick which service delivery you are wanting:
I have read and understood the following policies:
You can view these policies in the footer of this website.
WE LOOK FORWARD TO WELCOMING YOU TO OUR CLINIC
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