Request for Appointment

Welcome to Northside Speech.

We would like to know a little about you. The purposes of this form are to:

give you some information about Northside Speech and how we work, to help you determine whether we are the right service for you and your family, and
collect the information required to determine whether we are able to provide you with the requested service, and
collect the information required to triage requests and allow us to manage the waitlist.

The information you provide is considered ‘health information’ under law. The information you provide is confidential and is stored securely, consistent with our Privacy Policy.

Our Privacy Policy and other terms and conditions are available at: https://northsidespeech.com.au/clinic-policies/

NOTE: If you are requesting appointments for multiple people (e.g. siblings), please complete a separate request for each person. While we try to offer appointments for siblings on the same day, it can confuse our computer system if you put multiple names on the same form.

Please note: you can save your progress and complete the form later, using the button at bottom of the page.

IS NORTHSIDE SPEECH THE RIGHT FIT FOR YOUR NEEDS?

Before you refer, we would like to tell you a little about our service and values, to help you make sure Northside Speech is the right fit for you and your family.

Our approach to therapy is focused on providing targeted and meaningful support to address specific needs and goals. Our goal is to ensure that each appointment is purposeful and aligned with your objectives, so we may not offer therapy solely for the sake of it. Instead, we are committed to working collaboratively to achieve meaningful progress in areas that are important to you.

INTERPRETER

Would it help you if we use an interpreter (signed or spoken language)? *

YesNo

Language for interpreter: *

IDENTITY

Who are you seeking an appointment for? *

Myself/my partnerMy child

First name: *

Last name: *

Child's first name: *

Child's last name: *

Date of birth: *

Child's date of birth: *

Phone: *

Email: *

Address (line 1): *

Address (line 2):

Suburb: *

State: *

Postcode: *

Parent / Caregiver's name: *

Phone: *

Email: *

REFERRAL INFORMATION

How did you hear about us? *

What are your current concern(s)? Please describe: *

When did you first become aware of this concern? *

Has anything changed (improved or worsened) this concern? E.g. surgeries/medications/self-help strategies? Please describe: *

Have you previously consulted a speech pathologist about this concern? Please describe: *

What do you want to get out of your speech pathology appointment(s)? *

What does your child like to do? What makes them happy? *

LOGISTICS

Please note that strict eligiblity criteria apply for the Clinics. See the linked pages for details. If we can see from your request and goals that your needs would be better met by a different Clinic, program, or Service, we will offer you an appointment in that program instead.

Availability preference:

NDIS package: *

NDIA-managed (agency-managed)Plan-managedSelf-managed

I understand that Northside Speech does not bulk bill, and that a gap fee will apply. To access a Medicare rebate, I have (or will have) a CDM referral from my GP. *

NEXT STEPS

Thank you for your interest.

We will read and process the information you have provided.

We will use the information you have provided to:

Determine whether we are likely to be able to provide the service you have requested. If we are not able to provide this service, we will suggest other provider(s) who may be able to assist you.
Triage your request, and apply our current waitlist and/or booking procedures.

If we need more information, we will contact you using the details you have provided.

We will inform you whether a waitlist currently applies, and if so we will provide an estimate of how long the wait is likely to be.

If we currently have any appointments available to meet your needs, we will contact you to book an initial appointment. We will provide you will more information about what this will involve, and we may request more information from you.

I confirm that the information provided in this form is true and correct, to the best of my knowledge. I understand that incomplete or misleading information may mean that Northside Speech is not able to provide me with the requested service.

*

I understand that Northside Speech is a paid service, and that fees will apply. The Fee Schedule is available on our website. I will be informed of fees before a service is provided. *

I understand that if I book an appointment and do not show up, Northside Speech will charge me in line with the current cancellation policy, available on our website. *

I understand that Northside Speech is a healthcare service, and does not provide childminding or tutoring services. I understand that I should expect to attend and actively participate in my child's appointments, throughout the assessment and treatment process. *

Name of signee: *

Signature: *

Clear

Date: *

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