New Client Intake Form (NDIS)

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

Name(Required)

First Last

Date of Birth(Required)

Pronouns(Required)

Birth Sex(Required)

Assigned sex at birth

Gender Identity(Required)

Cultural Identity(Required)

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

Yes

Best Contact Number(Required)

This person will be contacted for arranging appointments

Email Address(Required)

Address(Required)

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

Covid Vaccination Status

Decision Maker(Required)

Informal Guardian Name(Required)

First Last

Legal Guardian Name(Required)

First Last

Enduring Power of Attorney Name(Required)

First Last

Informal Guardian's Relationship(Required)

Enduring Power of Attorney's Relationship(Required)

Legal Guardian's Relationship(Required)

Informal Guardian's Contact Details (Phone/Email)(Required)

Enduring Power of Attorney's Contact Details (Phone/Email)(Required)

Legal Guardian's Contact Details (Phone/Email)(Required)

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

Who is Your NDIS Plan Nominee(Required)

Emergency Contact details if different to above

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)

If yes, please email our team a copy.

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

Doctor's Medical Summary(Required)

If yes, please email our team a copy.

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 (Email Address, and Phone Number)

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

Please upload Functional Capacity Report or email a copy to our team.

Max. file size: 50 MB.