Name of person completing this form:
*
First Name
Last Name
Relationship to child:
*
Child's name:
*
First Name
Last Name
Child's date of birth:
*
Child's gender:
*
I require:
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Speech Therapy
Occupational Therapy
Both
Please note for Speech Therapy:
The wait time may be up to 6 months for daytime speech therapy appointments and up to 10 months for before and after school speech therapy appointments.
Please note for Occupational Therapy:
Occupational therapy services are currently offered on Thursdays and Fridays. The wait time may be up to 4-6 months for an Occupational Therapy appointment.
Would you be open to Telehealth Services for Occupational Therapy?
*
Yes
No
Speech Therapy: I would like to:
*
Book an assessment & therapy (if recommended)
Book an assessment only
Book therapy only (a speech assessment has been completed elsewhere)
Occupational Therapy: I would like to:
*
Book an assessment & therapy (if recommended)
Book an assessment only
Book therapy only (an OT assessment has been completed elsewhere)
Availability for therapy (please list days and times):
*
Please tick areas that your child is having difficulty:
*
Speech/Articulation (pronunciation of sounds)
Receptive language (understanding)
Expressive language (using words/sentences)
Fluency (stuttering)
Literacy (reading, spelling, writing)
Voice quality
I'm not sure
Other
Please tick areas that your child is having difficulty:
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Gross motor skills
Fine motor skills
Self care skills
Feeding therapy
Sensory processing
Emotional regulation
Cognitive skills
I'm not sure
Other
Please describe your concerns for your child in further detail:
*
Does your child have any formal diagnosis?
*
Yes
No
Please list all diagnoses:
*
Does your child have NDIS funding?
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Yes
No
Type of NDIS funding:
*
Self-managed
Third-party managed
NDIA managed
Unfortunately, we are currently unable to service clients whose NDIS funds are NDIA/Agency Managed. We apologise for any inconvenience. Please feel free to contact us again if there are any changes to the management of your funding.
Contact Email
*
example@example.com
Contact Number
*
Please enter a valid phone number.
Best time for us to contact you (please list days and times):
*
How did you hear about us?
*
Signature
*
Once you have submitted this form, you will receive an automated email response from us to confirm you have been added to our waiting list. If you do not, please check your spam/junk folder. Once there is a suitable availability for your child, you will be contacted by one of our therapists.
*
I understand
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