Page title

Hello!

Divider Text

Client Information

Child's First Name

Child's Last Name

Date of Birth

First Language

Other Languages

Divider Text

Parent/Carer's Information

First Name

Last Name

Mobile Number

Relationship to client

Divider Text

Elegibility

Browse

Low Income Health Card

Community Health Clinic

Upload evidence of an eligible visa

Browse

Visa

Divider Text

Area's of concern

Please indicate

To make multiple selections

On a PC Hold "Shift"

On a Mac Hold "Command"

Key Concerns

Other Concerns

Please upload a 1-2 minute video of you and your child interacting during play or a game

Browse

Conversation Video

History of services from other allied health professionals (e.g. OT, Psych)
Reasons for seeing allied health professionals

Other Health Services

List any medical diagnosis or medical history that may impact speech or language (e.g. insertion of grommets, removal of tonsils/adenoids, dentition concerns)

List any known diagnoses provided by a medical professional (e.g. Down Syndrome, ADHD, Autism, ODD)

Medical History

In submitting this form, you are confirming that:

My child is not currently eligible for NDIS funding
My child is not currently receiving speech pathology elsewhere
I understand that we are committing to attending the full sponsorship
I understand my child will be seen by a student speech pathologist under the supervision of a qualified speech pathologist.

SUBMIT