Welcome to Indigo Speech Pathology!
We are currently accepting referrals for private patients and NDIS participants who are self or plan managed
Participant's Name
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First Name
Last Name
Participant's Date of Birth
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Month
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Day
Year
Date
Phone Number
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Participant's Diagnosis (if none, leave blank)
Participants Address
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Participant/Parent/Guardian's Email
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example@example.com
Area of concern
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Language (e.g., aphasia/word-finding difficulties)
Dysphagia (e.g., difficulty swallowing food or drink)
Voice - (e.g., soft/hoarse/loss of voice/loudness)
Speech/Dysarthria (e.g., slurred speech)
Social Skills (e.g., difficultly interacting with others)
Assitive Augmentative Communication (AAC) (e.g, eye gaze devices, communication apps, picture communication
Fluency (e.g., stuttering)
Cognitive Communication (e.g., decline in memory, difficulty with planning/thinking clearly)
Literacy (Difficulty with reading and writing)
Referral Reason/Goals:
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Funding Type
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NDIS
Private
NDIS Number:
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NDIS Plan End Date:
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Month
-
Day
Year
Date
If NDIS managed, are you:
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Plan Managed
Self-Managed
The participants GP (Include name of GP and clinic if known)
Plan Manager Email
*
example@example.com
Home Visit Risk Screen (HVRS)
Does anyone in the house smoke? *Occupants are requested not to smoke during the visit.
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Are there any environmental hazards? E.g. hoarding, significant disrepair, poor hygiene etc
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Therapy services are $193.99/hour. We require your agreement to a minimum 10 hours of services to commence. This will include an initial assessment, travel to and from your location and a report. If you don't need a report or if less time is required then we won't charge the full 10 hours. Please check the box below to indicate your agreement.
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I agree with the above terms
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