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*

Our initial consultations take approximately one hour to complete face to face, and another 2-3 hours behind the scenes to complete the report. Should you need to cancel your appointment, a fee will be charged if you do not provide 2 business days’ notice.

ASSESSMENTS

Note - Medicare does not provide a rebate for the initial consultation. Rebates can be sorted from your private health insurance.

Complex assessments are for all clients on the NDIS and clients whose care requires more complex assessment and reporting. We will spend 1.5 hours completing the assessment and 1.5 hours writing the report. If on the day the assessment is less complex and we only require 1 hour to complete the assessment the fee will be $475.

Basic Assessments. As some clients do not require the time for the assessment and reporting the fees are reduced to 1 hour for assessment and 1 hour for the report ($380).

We will discuss prior to booking in an assessment if your child requires a complex assessment or a basic assessment.

Should you have a report issued by another Speech Pathologist within the last year you may not require an assessment but may be able to go directly to our therapy waiting list – we must also receive a copy of this prior to your initial appointment being booked.

TREATMENT SESSIONS (45 Min)

Each session is $145.50 (charged at the current NDIS rate of $193.99). This 45 minutes is made up of 30 minutes for face to face time with your child and 15 minutes after each therapy appointment to write a "Speech Pathology Session Summary".

This Speech Pathology Session Summary helps

Communicate the progress in therapy with families
Communicate the next steps moving forward
Communicate with preschool and schools vital information that will assist your child's communication progress outside of the clinic.
Support the policies of the NDIS and Speech Pathology Australia (which emphasis the need for therapists to clearly communicate all steps of therapy with the families).
From time to time some clients time in therapy will be short and this communication will not be required. If this is your child this will be discussed at the assessment.

CHRONIC DISEASE MANAGEMENT MEDICARE BENEFITS REBATE

If you wish to use this scheme, please familiarise yourself with the requirements of this benefit. It is your responsibility to ensure that your referring doctor supplies the documentation as detailed, as this practice is not authorised to request referrals on your behalf.

The following is a summary of the process:

The initial referral may be made by a General Practitioner. A referral letter to this practice is required in order for a consultation to be invoiced as a Medicare item. This step entitles you to five claimable consultations.

You are required to pay the full amount at the end of your session and claim back the rebate from Medicare.

PRIVATE HEALTH INSURANCE

Private health insurers provide partial rebates for Speech Pathology services, which may be used instead of, or following, use of Medicare rebates. 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 FUNDING

Hurstspeech 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 plan to your therapist on your first appointment. NDIS Clients - Please bring a copy of your NDIS paperwork with you to the initial evaluation

SCHOOL and PRESCHOOL SERVICES.

Hurstspeech is on the move offering a Mobile Service Delivery.

Hurstspeech has always worked closely with schools and preschools in Parramatta and the surrounding areas. We are now offering children a convenient way to work one-on-one with your speech pathologist during school time at their school or preschool.

These sessions can be conducted in a quiet area of the school or the classroom depending on the needs of your child and the availability of space at your child's school.

Fees will apply for travel time.

NOTE - due to staffing this is only occuring at the Parramatta location.

Preferred location of services*

Clinic based services SingletonClinic based services ParramattaMobile services to school and preschool (Parramatta only)Combination of mobile and clinic based services (Parramatta only)

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:

SCHOOL and PRESCHOOL SERVICES.

Singleton

Parramatta