Enquiry Form

Did you know that Talkativity is transitioning to ORS group from the 1st of March?

In addition to Speech Pathology and Occupational Therapy, ORS are also able to offer Dietetics, Psychology, Positive Behaviours Support and Physiotherapy.

Please click here to complete the new referral form

https://www.orsgroup.com.au/ors-referral/

Client Details (the person requiring services)

Date of referral

Date

Full Name*

First NameLast Name

Date of Birth*

DayMonthYear

Gender*

Other

Have you attended Talkativity before?

Yes, for this clientYes, for a sibling/family memberNo

Name of related client (optional)

Has someone recommended that you contact us?

YesNo

Please tick appropriate box

Name of referrer

Why did they recommend you contact us?

Briefly describe your concerns

0/150

Are there safety concerns?

e.g. falls, swallowing, urgent equipment requests

Please describe

What are your goals? What would you like to achieve from this service?

Does the client have a diagnosis?*

YesNo

Please list

Is the client an NDIS participant?

YesNo

How is the clients NDIS funding managed?

Please note, Talkativity is not NDIA registered. If you have an NDIS plan which is NDIA managed please call (03) 5941 9852 or email hello@talkativity.com.au before proceeding with this form.

Have you nominated a Plan Manager?

Who is your nominated Plan Manager:*

Company Name

If you would like to pay via credit card, please complete and return our Credit Card Authorisation form so that we can charge your nominated card directly following your appointments.

Please email me your Credit Card Authorisation form

Services you are enquiring about

Select which appointment type(s) you require*

Speech PathologyOccupational TherapyDevelopmental Education

Availability*

Location for appointments (choose all appropriate)

Pakenham ClinicBeaconsfield ClinicHomeSchool

If you would like school based visits please specify school name and suburb

Please upload any files that may assist us

Browse Files

Contact Information

All correspondence regarding appointments will go to the contact listed below.

If you are filling this out on behalf of another person requiring services, please consider who needs to receive this correspondence.

Contact name *

First NameLast Name

Relationship to client*

Phone number*

Email*

example@example.com

Is there external deadline that these services are required by?

e.g. funding application deadline, funding ending, NDIS planning meeting

Please describe

We will email clinical correspondence to you rather than post unless you nominate otherwise. If you do not wish correspondence to be sent to you via email please check this box

I do not wish to be sent information via email

We send text messages to clients to notify them of appointment availability.

This is okThis is not ok

We will email clinical correspondence to you rather than post unless you nominate otherwise. If you do not wish correspondence to be sent to you via email please check this box

I am happy to receive information including appointment notifications via emailI do not wish to be sent information via email

Please enter your address below*

Street Address

Street Address Line 2

SuburbState

Postcode

Client Declaration:

I confirm that I am the client listed above or their legal guardian and I have the authority to consent to the services listed above.

I understand Talkativity is a private service. Fees apply for services even when a referral is provided. More information is available on our website.

Is there any other information that would be helpful for us to know?

IMPORTANT

You will receive an email from Talkativity confirming that we received your submission.

To avoid this email and any other correspondence from Talkativity going to your junk folder, please add hello@talkativity.com.au to your contact list.

Talkativity needs to collect information about you for the primary purpose of providing a quality service to you. In order to thoroughly assess, diagnose and provide therapy, we need to collect some personal information from you. This information will also be used for:
a. The administrative purpose of running the practice;
b. Billing either directly or through an insurer or compensation agency;
c. Use within the practice if passing your case to another speech pathologist within the practice for ongoing management;
d. Disclosure of information to your doctors, other health professionals or to teachers to facilitate communication and best possible care for you; &
e. In the case of insurance, funding or compensation claim it may be necessary to disclose and/or collect information that affects your formal education or return to work where applicable.

Talkativity has a Privacy Policy that is provided to you at your initial consultation, available on our website and Facebook page and is on display in the clinic room. A printed or emailed copy is available on request from reception. This policy provides guidelines on the collection, use, disclosure and security of your information.

To ensure the process of quality treatment provision, information about your assessment results and progress may be given to relevant other service providers who are involved in your management. These may include your doctor, teachers, specialists, insurers, solicitors, employers or others, but only where it is considered to be of benefit to your progress. We will always ensure we have your permission to share this information prior to doing so.

I want to see a copy of the Privacy Information Statement

YesNot now

Declaration

By signing below I agree that:

I have read the above information and understand the reasons for collecting the information and the ways in which my information may be used.
I understand that it is my choice as to what information I provide and that withholding or falsifying information may act against the best interests of my assessment and therapy progress.
I am aware that I can access my personal and treatment information on request and if necessary, correct information that I believe to be inaccurate.
I understand that if, in exceptional circumstances, access to my information is denied for legitimate purposes, that the reasons for this and possible remedies will be made available to me.
I understand that the practice must obtain additional consent if the information collected is to be used in any ways other than that outlined above.

Name*

First NameLast Name

Signature*

	Monday	Tuesday	Wednesday	Thursday	Friday	Saturday
Morning
Mid-day
Early afternoon
After school

Talkativity Enquiry Form

Privacy & Consent