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.Please enable JavaScript in your browser to complete this form.Name *FirstLastPreferred PronounsChild's preferred pronounsHe/HimShe/HerThey/ThemOtherIf OtherDate of birth *Child's age *Home address *School detailsFirstMiddleLastOr Kinder nameOr Childcare nameWhat language is spoken at home?Parent / Caregiver / Legal guardian #1 *FirstLastPreferred Pronouns *Preferred pronounsHe/HimShe/HerThey/ThemOtherIf Other *Phone & Email *FirstLastParent / Caregiver / Legal guardian #2FirstLastPreferred Pronouns *Preferred pronounsHe/HimShe/HerThey/ThemOtherIf Other *Phone & EmailFirstLastIs the child of Aboriginal or Torres Strait Islander origin? *NoYes, AboriginalYes, Torres Strait IslanderYes, both Aboriginal and Torres Strait IslanderIs there a family court order in place? *YesNoTick all that applyPrivate Health InsuranceMedicare (Chronic Disease Management Plan) ReferralNational Disability Insurance Scheme (NDIS - select your plan below)If you ticked NDIS, what applies to you?Self-managedPlan managedPlease note that our clinic is not registered to provide services to Agency Managed NDIS ParticipantsWho 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? *YesNo 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? *YesNoReason for ReferralPlease 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 soundsIs understood by othersFollows directionsUnderstands or keeps up with conversationsJoins groupsMakes and maintains friendships with peersPlays with a range of toys or engages in a range of activitiesPlays with peersReads, spells, or understands written textExpresses their emotionsInitiates and maintains attention and focusSpeaks fluentlyPlease provide any further information below:Is or has the child been involved with any other health professionals?PaediatricianAudiologistOrthodontistPsychologistOptometristChiropractorOccupational TherapistEar Nose and Throat SpecialistPhysiotherapistOtherIf so, please list their name and contact information, and upload any relevant reports.1st Healthcare ProfessionalPaediatricianPsychologistOccupational TherapistAudiologistOptometristEar Nose and Throat SpecialistOrthodontistChiropractorPhysiotherapistTutorOtherHealth Professional nameName of practicePhone numberEmail address2nd Healthcare Professional PaediatricianPsychologistOccupational TherapistAudiologistOptometristEar Nose and Throat SpecialistOrthodontistChiropractorPhysiotherapistTutorOtherHealth Professional name Name of practice Phone number Email address 3rd Healthcare Professional PaediatricianPsychologistOccupational TherapistAudiologistOptometristEar Nose and Throat SpecialistOrthodontistChiropractorPhysiotherapistTutorOtherHealth Professional name Name of practice Phone numberEmail address 15. Has the child seen a Speech Pathologist before? If yes, please submit all relevant reports. *YESNOUpload 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 preferenceAdditional comments or message?I have read and understood the following policies: *Personal and Health Information Collection Statement for Minors, Disclaimer, terms and ConditionsYou can view these policies in the footer of this website.PhoneSubmit WE LOOK FORWARD TO WELCOMING YOU TO OUR CLINIC CONTACT OUR CLINIC