Waiting List Enrolment Form

Waiting List Enrolment Form

Loud and Clear provides services to children aged 4 to 13 years old experiencing difficulties in the areas of literacy, language, and speech. If your child requires assistance in the areas of social skills, pragmatic language, or behaviour management, contact us for a list of other practices that we recommend.
Child's Name*

First NameLast Name
Child's Birth Date*

DayMonthYear
Child's Gender*
Parent/Guardian's Name*

First NameLast Name
Relationship to Child*
Parent/Guardian's Email*
Contact Number*
Child's school year level / childcare / kindergarten:*
Does your child attend any of the following primary schools? [We provide a separate service at these schools and the wait may be shorter.]

Templestowe Valley PSSt Kevin's PS (Templestowe Lower)
Child's school/kindergarten if not listed above (OPTIONAL):
Does your child receive government funding?

NDIS self-managedNDIS plan-manangedFaHCSIA
If your child has a diagnosis of Autism Spectrum Disorder (ASD), please advise which level:

Level 1 - Requiring SupportLevel 2 - Requiring Substantial SupportLevel 3 - Requiring Very Substantial SupportOther
Does your child have another diagnosis / condition / difficulty that we should be aware of?
Concerns and Areas of Difficulty
Do you feel that your child has difficulties with understanding language (e.g. following instructions or stories, understanding words or concepts)?*
Do you feel that your child has difficulties with producing language (e.g. vocabulary, describing things, sentence structure, telling a story about past events)?*
Do you feel that your child has difficulties with producing speech sounds (e.g. lisp, can't say some sounds, has difficulty with pronunciation of words)?*
Do you feel that your child shows signs of stuttering (e.g. gets ‘stuck’ on certain words, has difficulty getting words out, repeats sounds or words)?*
Do you feel that your child has difficulties with literacy skills (e.g. struggles with spelling, writing, reading, letter names/sounds)?*
Do you feel that your child has difficulties with hearing (e.g. not responding to their name, appears to have 'selective hearing', doesn't respond to questions or instructions)?*
Do you feel that your child has difficulties with social skills (e.g. eye contact, sharing/taking turns, difficulty making friends)?*
Do you feel that your child has an unusual voice quality (e.g. ‘croaky’ voice, sounds like they always have a cold)?*
Availability

Providing your availability allows us to find you an appointment as efficiently as possible. Please note, there is a high demand for after school appointments and the wait for these times is longer.

Please select your desired appointment days and times:*

	9am-12pm	12pm-3:30pm	After 3:45pm
Monday
Tuesday
Wednesday
Thursday
Friday

Where would you prefer sessions to take place (select one or more)?*

Lower Templestowe clinicSchool / kindergarten / daycareOnline - telehealthOther
Briefly describe what areas or skills you would like your child to target in therapy:

Please enter into the box below
Comments or further information?

Please enter into the box below
Type a question
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Waiting List Enrolment Form

Concerns and Areas of Difficulty

Availability

Briefly describe what areas or skills you would like your child to target in therapy:

Comments or further information?