Waiting List Intake Form

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:
Which clinic location best suits you?Frankston (65 Beach Street, Frankston)Cheltenham (Unit 5 - 1253 Nepean Highway, Cheltenham)
Note: Our Cheltenham clinic is located on ground level, Unit 5

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?Speech TherapySwallow AssessmentOne off AssessmentTelehealthOngoing appointments in clinicNDIS - School funded AssessmentsClinic visitsOnsite visits eg school, kinderOther– please specify
Other – please specify:

Do you/the client receive funding for speech pathology services? NDISEnhanced Primary Care (EPC)No 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