New Client Intake Form (NDIS)

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New Client Intake Form

Before we can arrange a Speech Pathology appointment, we need to confirm the below information. Please complete the form at your earliest convenience. If you have any difficulties, please contact our friendly team.

As a new client of Speak and Swallow, we need you to complete the below information at your earliest convenience.

Are You Interested in Home or Clinic Visits?(Required)

Home Visits Only

Clinic Visits Only

Unsure

Name(Required)

First Last

Date of Birth(Required)

DD slash MM slash YYYY

Gender(Required)

Birth Sex(Required)

Gender Identity(Required)

Best Contact Number(Required)

Email Address(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Covid Vaccination Status

Next of Kin Name(Required)

First Last

Next of Kin Contact Details (Phone/Email)(Required)

Next of Kin Relationship(Required)

EPOA Name(Required)

EPOA Contact/Email(Required)

EPOA Relationship(Required)

Who is Your NDIS Plan Nominee(Required)

Emergency Contact details if different to above

Do you identify as Aboriginal or Torres Strait Islander?(Required)

Yes

Cultural Identity(Required)

Support Coordinator (If you have one)

NDIS Primary Diagnosis(Required)

As documented by the NDIS

Medical History(Required)

Is an Advanced Health Directive in place?(Required)

Yes, one is in place

No, there is none in place

If yes, please email our team a copy.

Is a DNR in place? (Do Not Resuscitate)(Required)

Yes, one is in place

No, there is none in place

If yes, please email our team a copy.

Has there been previous Speech Pathology input? If yes, please list details of previous Speech Pathologist below.

Is there a PBSP / Safety Plan in place?(Required)

Current Doctor's Details (name + practice)(Required)

Doctor's Medical Summary(Required)

NDIS Number(Required)

NDIS Plan Dates(Required)

NDIS Goals (Please outline below)

NDIS Plan: Self or Plan Managed?(Required)

Self Managed

Plan Managed

NDIS Plan Manager Details and Email Address

if applicable

NDIS Funding Allocation for Speech Pathology Services(Required)

Reason for Referral(Required)

e.g. swallowing assessment, communication assessment

Please upload any relevant service provider/medical reports or email a copy to our team.

Max. file size: 50 MB.

e.g. Occupational Therapist, Physio, ENT

Speak and Swallow

Speak and Swallow is a private practice offering a variety of speech therapy services for adults and adolescents in Greater Brisbane.

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