INTAKE FORM
admin@thespotco.com.au | thespotco.com.au | 03 9078 9999 | @thespeechandotco
Date
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Day
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Month
Year
Client Information
Name
First Name
Last Name
Preferred name
Pronouns (he/him, she/her, they/them)
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Date of birth
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Day
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Month
Year
Please note that we can't offer ongoing appointments for children aged 11+ due to wait times, but can offer intensive blocks or assessments during school holiday periods.
Address
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Street Address
City
State
Postcode
Language(s) spoken at home
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Interpreter required
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Please Select
Yes
No
If yes, what language?
Relevant diagnosis/es
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Allergies
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Medical History
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Services Required
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Ongoing appointments
Assessment
Intensive therapy block
Ongoing service required
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Speech Pathology
Occupational Therapy
Allied Health Assistant
Assessment required
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Autism
Language
Speech Sound
Literacy
Feeding
Alternative and Augmentative Communication (AAC)
Handwriting and Pre-Writing
Fine Motor
Self-Care (toileting, dressing, feeding)
Kinder/School
I'm not sure
Intensive therapy block required
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Speech Pathology
Occupational Therapy
What areas do you believe your child requires assistance with?
Attention/Concentration
Behaviours
Feeding and Eating
Gross Motor Skills
Fine Motor Skills
Handwriting
Language: Expressing
Language: Understanding
Play skills
Reading
School Transition
Self Care (toileting, dressing)
Sensory Regulation
Emotional Regulation
Speech Sounds
Stuttering
Other
In detail, please indicate your reason for seeking out The Speech & OT Co.
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How did you hear about us?
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Funding
How are you funded?
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Privately funded
Medicare (Chronic Disease Management Plan - CDMP/EPC/TCA)
National Disability Insurance Scheme (NDIS)
Private Health Insurance
If you're funded by the NDIS, please specify how your plan is managed below
Please Select
Self-Managed
Plan-Managed
Agency-Managed
Please note, The Speech & OT Co. is a non-NDIS registered provider and can only service Plan-Managed and Self-Managed Participants.
NDIS Number
NDIS Plan Dates
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Day
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Month
Year
Start Date
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Day
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Month
Year
End Date
Family Information
Parent/Carer/Guardian 1
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Relationship to child
*
Email
*
example@example.com
Address (if different from child)
Street Address
Street Address Line 2
City
State
Postcode
Phone Number
*
Please enter a valid phone number.
Parent/Carer/Guardian 2
Relationship to child
Email
example@example.com
Address (if different from child)
Street Address
Street Address Line 2
City
State
Postcode
Phone Number
Please enter a valid phone number.
Best contact method
Email
Post
Phone call
Text message
Siblings
Yes
No
Sibling(s) names and ages
Family court orders pertaining to your child
*
Yes
No
If Yes, please specify
Education Setting Information (Day care, kindergarten, school)
Education Setting Name
Educator's Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
External Services Involved
General Practitioner
Paediatrician
Maternal Child Health Nurse (MCHN)
Allied Health Practitioners (OT, Speech, Physiotherapy, Dietetics)
I provide consent for The Speech & OT Co. to contact the above professionals
Yes
No
Other
Service Information
Desired location of sessions
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Chelsea Clinic - Applicable to SE clients only
Glenroy Clinic- Applicable to North clients only
Childcare, kindergarten, school
Home visits
Other
Are you open to telehealth sessions if this means that your child can be seen faster?
Yes
No
Please choose 3 preferred days that suit you best for ongoing sessions
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Monday
Tuesday
Wednesday
Thursday
Please choose time slots that suit you best for ongoing sessions
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Morning 9:00am-11:30am)
Early afternoon (12:00-2:00)
Late afternoon (2:00 - 3:30pm)
Desired frequency of sessions
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Please Select
Weekly
Fortnightly
Our goal is to provide quality care to all our families in a timely manner. No-shows, late arrivals, and cancellations impact not only the therapists, but other families on our wait list. Any cancellation made less than 48 hours will result in a cancellation fee of 90-100% of the session fee. Appointments are in high demand, and your advanced notice will allow another patient access to that appointment time. By ticking the below box, you understand and consent to our cancellation policy.
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Yes
No - Please exit the form as we are unable to provide service
Anything you wish to discuss in our initial meeting
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Submit
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