Client's First Name

Client's Last Name

Client's Date of Birth

Client's Age

Client's Gender

Client's School

Parent/Guardian's Details:

Contact Details

Phone

Home Address

Postal Address (leave blank if the same as above)

Referral Information

Referrer Address

Referrer's Phone

Referrer's Email

Reason for referral

Relevant Medical History

Client's Diagnosis (if any)

Any hearing concerns? Any hearing concerns? Yes No

Any middle ear infections Any middle ear infections Yes No

Has your child had a hearing assessment or been seen by an ENT? Has your child had a hearing assessment or been seen by an ENT? Yes No

If yes, please provide more information

Aboriginal or Torres Strait Islander? Aboriginal or Torres Strait Islander? Yes No

If yes, please specify

Private Insurance Private Insurance Yes No

If yes, please specify

Does the Client have NDIS funding for speech therapy? Does the Client have NDIS funding for speech therapy? Yes No

If yes, please specify If yes, please specify Self Managed Plan Managed

If yes, NDIS Participant Number

Preferred Days for therapy sessions Preferred Days for therapy sessions Monday Tuesday Wednesday Thursday Friday No preference

Preferred times for therapy sessions Preferred times for therapy sessions Morning Late Morning Afternoon After School No preference

How did you hear about us? How did you hear about us? Google GP/Specialist Referral Family/Friends Socials Other

Other