New client intake form

1
Your name* This field is required.
First Name
Last Name
2
Your child's name* This field is required.
First Name
Last Name
3
Child's date of Birth* This field is required.
Date
Day
Month
Year
4
Your relationship to child* This field is required.
Parent/ Caregiver
Relative
NDIS coordinator/ Case Manager
Other
5
Your best mobile number* This field is required.
Please enter a valid phone number.
6
Your best email address* This field is required.
example@example.com
7
Where did you hear about us?* This field is required.
Google
General Practioner (GP)
Maternal child nurse
Instragram
Facebook
Current / Previous client
NDIS coordinator
Kinder / School (including disability leader)
St Thomas Basketball Club
Diamond Valley Little Athletics
Paediatrician
Other Allied Heath provider (OT, Pysch etc..)
Other
8
Is your child receiving any funding?* This field is required.We require a copy of your child's NDIS plan
Yes (NDIS Self managed)
Yes (NDIS Plan managed)
Yes (NDIS Agency managed)
Yes ( I have a Medicare care plan from my GP)
Yes (Unsure what though)
No (paying privately)
9
Has your child been diagnosed with a medical condition or has a disability that you would like to share with us?
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Large
Normal
Small
Ok
Ok
10
What are your concerns about your child's communication?* This field is required.Select as many that apply
Language Delay (lack of words)
Speech Sounds
Autism
Stutter
Behaviour
Social language / interactions
Literacy
Other
11
What others concerns do you have about your child's communication?
12
What services are you looking for?* This field is required.
Assessment & therapy (if required)
Assessment ONLY - Immediate Appointments Available
Therapy Sessions ONLY - If your child has had a recent assessment completed at another provider and you are able to provide a copy of the report.. If more detail is needed, our Speech Pathologist may need to complete an additional assessment and report.
13
What are your preferred session day/times? (Select as many that apply)* This field is required.Our first session time is 8am and our last session time is 4pm, We do not work on the weekends. Our last session time on Friday is 1pm. Session times are booked for the same time either weekly or fortnightly
Extended hours Monday 5 - 6pm
Monday morning
Monday afternoon
Tuesday morning
Tuesday afternoon
Wednesday morning
Wednesday afternoon
Thursday morning
Thursday afternoon
Friday morning
14
Where would you like to receive services? (Select as many that apply)* This field is required.Please note we do not work on the weekends. Our last session time on Friday is 1pm. Session times are booked for the same time either weekly or fortnightly.
Bundoora Clinic
Greensborough Clinic
Telehealth (Online Consultation)
Offsite - childcare or education setting (We do not offer in home services)
I dont mind - I want the earliest appointment available
15
If requesting offsite services in a daycare / educational setting, please provide name of organisation, address, email, phone and contact person
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Large
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Small
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Ok
16
Have you in the past or are you currently accessing speech pathology from another provider? If yes, please list details.If you would like to access two speech pathologists at once, we would need to liaise with the other provider to ensure ethical, safe and effective therapy services for your child. *additional charges may apply
17
When you like to start services? * This field is required.Please either enter ASAP, if unable to start now, please write when and why.
18
I have completed this form truthfully and to the best of my knowledge* This field is required.Signature
Clear
19
Date form was completed* This field is required.
Date
Day
Month
Year
Should be Empty: