Intake Form

Carers Name*

First NameSuname

Child's Name*

First NameSuname

Age of the child*

Address*

Street Address

Street Address Line 2

SuburbState

Post Code

Child's Date of birth*

Date

If you are not the legal guardian, does the legal guardian give you consent to act on their behalf?

YesNo

Are you the legal guardian*

YesNo

Are there any court orders relating to the child that we need to be aware of?

YesNo

Phone Number*

Area CodePhone Number

E-mail*

FEES

ASSESSMENTS
• NDIS Assessment: 1 hour face-to-face + 2 hours report writing. Billed at $193.99/hr. Total cost: $581.97.
• Private Assessment: 1 hour assessment + 1.5 hours report writing. Cost: $475.

THERAPY SESSIONS
• NDIS Therapy Session: $161.65 (includes 30 min face-to-face plus time for notes, home program design, and preparation).
• Private Therapy Session: $160 (30 min face-to-face; additional time is allocated for documentation, preparation, and home program design as required).

ASSESSMENTS

NDIS ASSESSMENT
Our NDIS assessments include 1 hour face-to-face assessment and 2 hours of report writing.
This service is billed at the current NDIS rate of $193.99 per hour.
Total cost: $581.97 (3 hours @ $193.99/hr).

PRIVATE ASSESSMENT
Private assessments include 1 hour assessment and 1.5 hours of report writing.
Cost: $475.

CANCELLATIONS
If you need to cancel your appointment, a cancellation fee will be charged if you do not provide 2 business days’ notice.

MEDICARE / PRIVATE HEALTH
Please note: Medicare does not provide a rebate for the initial consultation. Rebates may be available through your private health insurance (please check with your fund).

TREATMENT SESSIONS

NDIS THERAPY SESSIONS
Fee: $161.65 per session.
Each session includes 30 minutes face-to-face therapy, plus time allocated for clinical note writing and home program design, and preparation time prior to the session.

PRIVATE THERAPY SESSIONS
Fee: $160 per session.
Private sessions include 30 minutes face-to-face therapy. Additional professional time is also allocated for clinical documentation, preparation, and home program design, as required.

CHRONIC DISEASE MANAGEMENT – MEDICARE BENEFITS REBATE
If you wish to use this scheme, please familiarise yourself with the requirements. It is your responsibility to ensure your referring doctor supplies the required documentation, as this practice is not authorised to request referrals on your behalf.

Summary of the process:
• The initial referral may be made by a General Practitioner. A referral letter to this practice is required for a consultation to be invoiced as a Medicare item. This entitles you to five claimable consultations.
• You are required to pay the full amount at the end of your session and claim the rebate back from Medicare.

PRIVATE HEALTH INSURANCE
Private health insurers may provide partial rebates for Speech Pathology services. A referral is not required to claim private health insurance rebates. You are required to pay the full amount at the end of your session and claim back the rebate from your health fund.

NATIONAL DISABILITY INSURANCE SCHEME (NDIS) FUNDING
Hurst Speech is a registered NDIS provider. Please provide details of how you will be funded in the Service Agreement. You MUST provide a copy of your NDIS plan to your therapist at your first appointment. NDIS clients: please bring a copy of your NDIS paperwork with you to the initial evaluation.

Name of preschool or school your child attends*

How did you hear about us?*

Please give naming of referring specialist

What are your concerns?*

Can your child hold a back and forth conversation?*

YesNo

Is your child currently seeing a Speech Pathologist?*

YesNo

Please provide details of any medical diagnosis or previous Speech Pathology reports.

Are there any behaviour issues? Psychologist / OT involved?*

Additional information about preferred appointment time.

How will the sessions be funded?*

Additional Information that may be helpful

Customer Details:

Singleton