Speech Pathology Referral Form

Speech Pathology Referral Form

Please fill out this form to refer a patient for speech pathology services.
Mallee Border Health Centre, Speech Pathologist, Kerri Wilson currently accepts referrals for children aged 0-18 years, offering support for the following areas of concern:
- Early language development support
- Speech sound intervention
- Listening and Understanding language
- Neurodiversity affirming approaches
- Classroom/ school advocacy support and guidance
- Stuttering
- Reading
- Writing
- Social Skills
- Learning
Clients may be referred for speech pathology services by any of the following individuals using the form below:
- Parent/ Caregiver
- Childcare/ Education provider
- GP/ NP/ Paediatrician
- Allied Health Professional (e.g. Occupational Therapist)
- NDIS Plan Manager or Early Intervention Provider
Child's Full Name*

First NameLast Name
Child's Date of Birth*

MonthDayYear
Date
Child's Gender*
Does the child identify as Aboriginal and/or Torres Strait Islander?*
Email*
Please make sure you have double checked that the email address is correct
Phone Number*
Please enter a valid phone number.
Referrer's Name:*

First NameLast Name
Referrer's occupation and organisation (if appropriate) and reason for referral:
Reason for referral:*
Parent/ Care Giver's Name (if different from above)*

First NameLast Name
Parent/ Caregiver's phone number: *
Parent/ Caregiver's email address:*
Please double check the email address is correct.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Current Funding Source if applicable (e.g. NDIS, medicare, private health, none):*
If you answered yes to being a NDIS participant, please provide your NDIS participant number and provider information below (please note services to children can be provided to children with a National Disability Insurance Scheme (NDIS) plan if they are 'plan managed' or 'self managed'):
What health care services are currently or have previously been accessed:*

Speech PathologyOccupational TherapyPaediatricianPhysiotherapySocial WorkPsychologySchool or Preschool Support ServicesOptometry/ Behavioural OptometryEar Nose and Throat SpecialistOther
Preferred Speech Pathology Location*
Specific Speech Pathology Services Required*

One Off Speech Pathology Assessment Prior to Funding Applications1:1 Speech Pathology SupportParent ConsultationAny/ All of the aboveOther
Further Information: Please include your current concerns e.g. speech sound development, dysfluency (stuttering), delayed use of words, developmental differences, literacy, behaviour, social skills) and what supports you are looking for?
Relevant Medical History and/ or Diagnosis:
Please upload any relevant assessment reports or documents (e.g. Previous Speech pathology reports, Diagnostic reports, current NDIS plan and goals

Cancelof
Would you like to be contacted if an assessment only appointment becomes available?

yesno
How we communicate:

Please note that our primary method of communication is via email. We will ensure that the email subject and content have the least amount of identifiable information in them while still being practical for the recipient, to ensure minimal risk for clients.
What are the risks of communication via email:

Within all forms of written communication comes some form of risk that the information can be read by someone other than the intended recipient. There is also the risk that the email could be sent to the wrong person and that emails are often accessed on portable devices, which are at risk of being lost or stolen (please note all portable devices are password encrypted). Emails can be forwarded or changed without the consent of the original sender.
I acknowledge I have read and understand the associated risks involved with communicating via email:*

Yes
Cancellation Policy

Cancellation: If, for some reason you need to cancel or postpone your appointment, please provide at least 24 hours notice, otherwise you may be charged a late cancellation/ non-attendance fee. This fee must be paid in full prior to the commencement of your next session. (Please note cancelled appointments are not covered by Medicare).
I acknowledge I have read and understood the above cancellation policy:*

Yes
Signature*

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Name of person signing form and relationship to child:*
Date:*
Should be Empty:

Speech Pathology Referral Form

How we communicate:

What are the risks of communication via email:

Cancellation Policy