Speak and Swallow Speech Therapy - New Client Intake Form

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.

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

Home Visits Only

Clinic Visits Only

Unsure

Name(Required)

First Last

Date of Birth(Required)

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)

Emergency Contact details if different to above

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

Yes

Cultural Identity(Required)

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.

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

Doctor's Medical Summary(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