Waiting List Enrolment Form

Waiting List Enrolment Form

Speak and Read provides services to children up to 12 years old experiencing difficulties in the areas of literacy, language, speech, and orofacial myology.
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:*
Child's school/kindergarten (OPTIONAL):
NDIS self-managedNDIS plan-manangedFaHCSIA
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)?*
Do you feel that your child has difficulties with oral rest posture (mouth breathing and/or low tongue resting position), tongue thrust swallow, drooling, messy/fussy eating, or tongue-tie?*
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:*

Rows	8am-12pm	12pm-3:30pm	After 3:45pm
Saturday

Ashburton 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
Please note that while responses are emailed directly to Speak & Read, we cannot guarantee the security of any website. Users should be aware that the internet is an unsecure public network that gives rise to a potential risk that a user's transactions are being viewed, intercepted or modified by third parties. Please contact us should you have any questions or would prefer to provide your details in an alternative form.
Should be Empty:

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?