Waiting List Intake Form

Welcome to Complete Speech Pathology Waiting List.

Please fill out the client/your details below.

If you need assistance with filling out the form, please contact us on 9781 4088.

    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?

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

    Have you/the client seen a speech pathologist before?
    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