Clone of New Patient Intake Form

Waiting List & New Patient Intake form:

If you are wanting speech pathology services, please fill out our step-by-step referral form below. We just need to know a little about you and the services you require, and we'll get you underway. If you have any questions while you are completing this form or need some help to complete it, simply contact us on 0499 602 666 or email daniel@wordsatplay.com.au.
Client's Full Name*

First NameLast Name
Client's Date of Birth*

DayMonthYear
Gender*
Pronouns
Client's Address*

Street Address

Street Address Line 2 /Unit no.

CityState

Post CodeCountry
Contact Person's Name*

First NameLast Name
Relationship to Client*
Main Contact Number*

Phone Number
E-mail*
Please provide the participant's primary diagnosis or suspected diagnosis and their health background (physical and mental)*
Participant's areas/goals to address in Speech Therapy*
Are there currently any court documents, guardianship orders, parenting orders, or custody orders in place that we need to be aware of that may impact provision of services?*
Are there currently any court documents, guardianship orders, parenting orders, or custody orders in place that we need to be aware of that may impact provision of services?*

YesNoN/A
If "Yes" is selected for the question above, please provide details regarding any court documents, guardianship orders, parenting orders, or custody orders in place that we need to be aware of that may impact provision of services:
If parents/guardians are separated, is custody of the participant/child shared?*

YesNoN/A
If "Yes" is selected for the above question, please provide details regarding custody of the participant/child:
Is the client currently (or have they) received therapy input elsewhere?

YesNo
Please provide details regarding therapy input received (Who, where, when, what did therapy focus on)?
Please provide the contact details for any other professionals that are involved in the participant's care (Paediatrician, GP, other specialists):
NDIS Plan Details

Please answer this section if you are an NDIS participant. For non-NDIS participant, please enter "N/A" or select any date for the questions in this section.
NDIS Participant Number
Fund Management Method
If Plan Managed, please provide name and email of Plan-Manager organisation
Information of LAC/ Support Coordinator (If any)
Name

First NameLast Name
Phone Number

CodePhone Number
Email
example@example.com
Appointment Availability

Online (Telehealth) Appointment are available upon request, please suggest any days and times that work best for you.
Client's availability*
Signature

Clear
Should be Empty:

Waiting List & New Patient Intake form:

NDIS Plan Details

Information of LAC/ Support Coordinator (If any)

Appointment Availability