Client Details
Join the waitlist for music therapy services by providing your information below.
Client Name
*
First Name
Last Name
Parent Name
First Name
Last Name
Email Address
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Birth
*
-
Month
-
Day
Year
Date
Preferred Contact Method
*
Email
Phone
Either
Preferred Days/Times for Sessions (select all that apply)
Weekday mornings
Weekday afternoons
Weekend mornings
Weekend afternoons
Other (please specify)
Music Therapy Goals
Reason for Seeking Music Therapy
*
Select your music therapy goals (tick all that apply)
Communication & language development
Social interaction & engagement
Emotional regulation
Attention & participation
Confidence & self-expression
Sensory regulation
Support alongside speech therapy goals
Other (please specify)
Briefly describe any prior experience with music or music therapy (if any)
Referral Information
Who referred you to Speech Bubble? (e.g. GP, School, Self, Allied Health)
Referring Professional (if applicable):
Reason for Referral / Main Concerns:
Is there anything else you would like us to know?
Current Supports
Is your child currently receiving Speech Pathology services?
Yes
No
If yes, please specify therapist / clinic:
Other Allied Health Supports: (e.g. OT, Psychology, Physiotherapy)
Previous Music Therapy Experience?
Yes
No
If yes, please provide details:
Funding Information
Funding Type
NDIS
Private
Medicare (EPC)
Other
If NDIS:
Plan Type
Self-managed
Plan-managed
NDIA-managed
Plan Manager (if applicable):
NDIS Number (optional at waitlist stage):
Consent
By submitting this form, you consent to Speech Bubble Speech Pathology collecting and storing this information for the purposes of waitlist management and service planning. You understand that completion of this form does not guarantee immediate service availability. You may withdraw from the waitlist at any time by notifying us in writing.
Name of Parent / Guardian:
*
Signature:
*
Date:
*
-
Month
-
Day
Year
Date
Join Waitlist
Should be Empty: