Client name: Person completing this form: Relation to client: Do you/the client speak a language other than English at home? (Please also note any cultural/religious needs) Date of Birth: Client Home Address: Contact name: Contact email: Contact number:
What are your concerns about your/the clients’ communication or swallowing? Please be specific (e.g., articulation/language/social skills/choking etc). What is your availability? What type of service(s) do you/the client require? Note: All swallow assessments will be conducted at our Frankston clinic, unless prior arrangements have been made. Clinic sessionsSwallow AssessmentOne off AssessmentReport for assessment (Charge may apply)Telehealth sessionsExternal visits – please specify External visits (Frankston area up to 30mins - Cheltenham area up to 30mins) – please specify address: Note: All initial sessions are to be held at our Frankston clinic.
Do you/the client receive funding for speech pathology services? Note: We are not affiliated with any Private Health companies, you must contact your insurer for more information. NDISGP Chronic Condition Management Plan (GPCCMP)My Aged Care PlanNo FundingOther – please specify Other – please specify: Have you/the client seen a speech pathologist before? YesNo If so, you may like to give a short explanation.
*Please note that wait times are dependent on the type of services required. There are currently longer wait times for the following: • Home visits due to the additional travel time needed. • After school appointments due to fixed number of appointments available.
