Intake Form

Thank you for reaching out to Beyond Speech. Completing this form gives us the information we need to understand the client’s needs and referral reason so that we can allocate the best Clinician to your care. The more detail you share, the clearer picture we’ll have of their abilities and support requirements. Please note, clients can only be added to our waitlist once this form is completed. If you’re unsure about any part, our Admin team is here to help.

Today's date: *

Name of person completing this form: *

Relationship to client: *

Contact Phone Number of Person Completing this Form *

Background history

Client's first name *

Client's surname *

Client's Date of Birth *Please ensure you use the date selector below; do not enter the date of birth manually

Sex *

Preferred Pronouns

Is the client: *

an adulta child

Address

House/unit number and Street: *

Town *

State *

Postcode *

Mother/Guardian's full name *

Father/Guardian's full name *

Next of Kin name: *

Mother/Guardian's Contact Number *

Father/Guardian's contact number *

Next of Kin contact number: *

Mother/Guardian's email *

Father/Guardian's email *

Next of Kin email: *

Guardian's relationship to client (where applicable):

Who lives at home with the child? *

Important client information

Are there any custody arrangements in place for this child? *

yesno

If yes, please add details:

Are there any Court Orders in place for this client? If yes, please forward to admin@beyondspeech.com.au *

YesNo

Are there any parenting orders in place that may affect consent for services? *

YesNo

Any other relevant information? (eg. family breakdown, illness or stress) *

Referral information

Who referred the client to Beyond Speech? *

School/Childcare/Kinder (if applicable): *

Employer (if applicable): *

Other professionals involved? *Please list all professionals currently supporting the client.

Diagnosis: *

Reason for referral: *

What services are you seeking? *

Speech PathologyOrofacial MyologyMusic Therapy

Details:

Other information

Client's strengths and interests: *

Can you and the client manage stairs? *

YesNo

Our main clinic is located at 206 Maroondah Hwy and there are internal stairs to some of our treatment rooms on the second level. Rooms on the ground floor can be allocated for clients who cannot manage stairs.

Is the client currently being seen by a Speech Pathologist? *

YesNo

Has the client been seen by a Speech Pathologist before? *

YesNo

If yes to either of the above questions, please provide details:

Do you have any reports from other professionals? *

YesNo

If yes, please upload your reports here (or you are welcome to email to admin@beyondspeech.com.au

Browse

Does the client have a behaviour support plan? *

YesNo

If yes, please upload a copy of the plan here

Browse

If 'other', please provide details:

Availability

Client availability: *Please nominate the days (Monday to Saturday) and times (AM, PM, AFTERSCHOOL) the client is available to attend Speech Pathology sessions.

What frequency of sessions does the client need? *

weeklyfortnightlymonthly

Funding

Funding (If any) *

NDIS Self-ManagedNDIS Plan-ManagedPrivate Paying Home Care PackageShort Term Restorative Care ProgramPrivate Health Insurance (gap payments will apply)Medicare HCWA (Helping Children with Autism referral from Paediatrician) (gap payments will apply)Medicare CDM plan (Chronic Disease Management referral from GP) (gap payments will apply)Other (Please specify below)

Other Funding

Home Care Package or Short Term Restorative Care Program provider name and contact details:

Email address for invoicing:

If NDIS Plan-Managed, please list the Plan Manager name:

NDIS Number

Plan Manager email:

If the client has a referral from GP or Paediatrician (CDM or HCWA), please complete Medicare details:

Medicare number:

Client Medicare Reference No:

If client is under 15 years of age, Parent/ Claimant Full Name:

Parent/ Claimant D.O.B:

Parent/ Claimant Medicare Reference No:

Communication:

This helps us understand how we can best communicate with the support person/next of kin of the client. Please add details if the client's preferred method of communication is different from that of their Next of Kin/Support person.

First name of best contact person for communicating about appointments: *

Best email for appointment correspondence: *

Best phone number for appointment correspondence: *

Other:Please add details if client's preferred method of communication is different from that of their Next of Kin/Support person

Do you need an interpreter? *

yesno

IF yes, state language:

Diversity

Is the client of Aboriginal or Torres Strait Islander Origin? *

yesno

Does the client and / or Next of Kin have religious or cultural needs we should be aware of in order to provide our best service? *

yesno

Does the client have any sensory preferences or differences that we should be aware of? *

yesno

If yes, please provide further details:

Advocacy

All clients are entitled to have an independent support person attend sessions and/or meetings to assist in decision making processes.

Does the client require a support person to help you to access our services? *

yesno

If yes, please provide details:

How did you find us?

How did you hear about us? *

Speech Pathology Australia websiteGoogle searchSocial Media (Instagram/Facebook)Recommended via friendRecommended via another allied health professionalRecommended via school/kindergarten

Thank you for completing our booking form. We will be in contact when we are able to offer you an appointment. For any questions, please feel free to contact us phone: 0417 035 016 or email: admin@beyondspeech.com.au

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