Farmhouse Chatter Referral Form

Farmhouse Chatter Referral Form
We appreciate your detailed responses to our waitlist questionnaire, which will help us quickly find the right client services for you.

You will not be guaranteed an appointment with us by filling out this form. This form helps us find a service to meet your specific needs and manage your position on the waitlist more efficiently.

If you need help completing this form, please get in touch with us at 0417 878 062 or speech@farmhousechatter.com.au.
Referrer Information:
Name of individual completing referral form:

First NameLast Name
Relationship to client (e.g. self, parent, support coordinator, etc.):
Email Address:
Contact Number:
Phone Number
E-mail
example@example.com

Client Details:
Client's full name:

First NameLast Name
Preferred name (if different):
Client's date of birth:

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
School (if applicable):

Client Point of Contact (if different from the referral information):
Name:

First NameLast Name
Your relationship to client:

SelfParent/CarerLegal guardianPersonal representativeOther
If you answered 'other' to the above question, please provide further details:
Email
example@example.com
Phone Number
Please enter a valid phone number.

Funding Type:
Please choose a funding option:

NDIS - Self ManagedNDIS - Plan ManagedMedicarePrivate Health InsuranceNo Funding (Private Paying)Department of Veterans' AffairsReturnToWorkSATransport Accident CommissionOther
NDIS Participant Number (if applicable)
NDIS Plan Dates (if applicable)
NDIS Plan Manager Company (if applicable)
Additional comments regarding funding (i.e. waiting on NDIS approval):

Additional questions:
Do any of the following apply?

Under Guardianship of the MinisterFoster family/alternative care arrangementCourt orderVoluntary out of home care / supported independent living2:1 support requirement
Any other information that you would like us to know:
Does the client/care team require an interpreter?

YesNo
If yes, which language?
Any other information that you would like to attach:

Cancelof

Cancellations, changes to bookings and failures to attend appointments:
In line with the NDIS Pricing Arrangements and Price Limits 2025–2026, our cancellation time frames have been updated to reflect the guidelines outlined for provider supports. We kindly ask for at least 48 hours’ notice for cancellations to avoid incurring the full session fee. This ensures consistency with sector standards and supports transparent, fair service delivery for all participants. If you need to cancel, reschedule, or are unable to attend an appointment, please notify us as early as possible. You can contact us by:

Email: speech@farmhousechatter.com.au
Phone: 0417 878 062
SMS text message
We must receive your message before your scheduled appointment time. Late cancellations or non-attendance with less than 48 hours’ notice will incur the full session fee. If 20% or more of your appointments are missed without sufficient notice, we reserve the right to conclude services for you or the person in your care.

I also acknowledge that if an appointment is cancelled with less than the required 48 hours' notice, as outlined in the clinic’s cancellation policy, a cancellation fee may apply, and further services may be paused until this fee is settled.

Consent for Use of AI-Assisted Note Transcription:
To support accurate and timely clinical documentation, our practice may utilise AI-assisted transcription tools to assist speech pathologists in documenting session notes. This technology is used solely to transcribe the therapist’s spoken reflections into written notes and is not used to analyse or interpret your child’s information. All data is handled in line with strict confidentiality, privacy, and security standards.

I understand that Farmhouse Chatter may utilise AI-assisted tools to support note transcription, enabling clinicians to efficiently and securely document therapy sessions. I acknowledge that these tools are used solely for transcription purposes, and all information is managed in accordance with privacy and confidentiality standards.
Comments or Questions
Name

First NameLast Name
Signature

Clear
Contact Information:

Farmhouse Chatter
Entity: PRZIBILLA, JASMINE ELLEN
Email Address: speech@farmhousechatter.com.au
Phone Number: 0417 878 062
PO Box 23, Pinnaroo 5304 South Australia
Website: www.farmhousechatter.com.au
Should be Empty:

	7:30am - 10:30am	10:30am - 3:30pm	3:30pm - 6:30pm	Any time
Monday
Tuesday
Wednesday
Thursday
Friday

Farmhouse Chatter Referral Form

Referrer Information: