I agree to Telehealth/Online sessions where in-clinic sessions cannot occur due to being unwell/respiratory systems e.g. COVID, Flu, Runny nose *

No - please exit this form as we do not offer only face to face appointment options

Yes - please continue

Are there any Court directed documents relevant to shared care of child?

No

Yes (A copy is required to be emailed for review. Please be advised we will need to include all persons named in communication in accordance with the documents. An assessment cannot be considered until the relevant legal documents have been reviewed)

Not relevant, client is not a child nor has any legal documents relevant to care

Your Name *

First Name

Last Name

Client's Name *

First Name

Last Name

Does the client have a medical diagnosis? *

Yes

No

Is the client involved with any other health professionals? *

Audiologist

Chiropractor

Dentist/Orthodontist

Ear Nose and Throat Surgeon

Occupational Therapist

Orthodontist

Osteopath

Myotherapist

Physiotherapist

Psychologist

Speech Pathologist

No other health professional

Other (note other health professionals below)

None

Is the client about to undergo or previously had any surgery e.g. Ear Nose and Throat for adenoids, tonsils, grommets, tongue tie release etc. *

Yes

No

Is the client currently undergoing or about to undergo or had any orthodontic care e.g. expansion, braces? *

Yes

No

Has the client even been assessed and told they have a tongue tie or upper lip tie? *

If yes, please provide more detail in the next 3 questions

Yes

No

Is anyone concerned about the client's ability to say sounds? *

Yes

No

Is anyone concerned about the client's ability to be understood at word, phrase, sentence or in conversation? *

Yes

No

Is anyone concerned about the client's behaviour? *

Yes

No

Flexible to attend assessment and therapy appointments Monday, Tuesday or Wednesday during school hours (time determined based on availability at time) *

Yes

No (if not please notes days/times below)

Prefer ongoing therapy appointments (not assessment) to be: *

In clinic

Online/Zoom

Either in-clinic or online/zoom

Payment Method: How will the sessions be paid for/funded? *

Private Health Insurance

Medicare Plan organised from GP

Privately funded

NDIS Self Managed

NDIS Plan Managed but parent/carer will pay for session themselves at end of session; and claim from plan manger themselves

Other (please note)

Preferred communication method for contact *

Email

Phone

Either