Parent's Name *

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Type of Service Required *

Please note that an assessment will be required if a previous speech pathology assessment has not been completed in the past 12 months.

Assessment only

Assessment with ongoing therapy

Therapy

Reason for Speech Therapy *

Please tick the relevant boxes in relation to the areas your child is having difficulties with.

Expressive Language - This relates to your child’s ability to express their needs, wants and thoughts.

Receptive Language - This relates to your child’s ability to follow instructions and understand verbal and visual information (comprehension.

Adolescent Speech Therapy - For assistance with reading comprehensions examination techniques, note taking, mind mapping, essay writing techniques and structuring assignments.

Literacy - For assistance with Dyslexia, Dysgraphia, Reading, Writing, Spelling, Study Skills, Phonological Awareness, Fluency and written Comprehension.

Speech Sounds - This relates to difficulty producing a sound, swapping a sound for another, unintelligible speech, articulation and phonological disorders.

Stuttering - This may relate to your child repeating sounds, words and phrase repetition and getting suck when talking.

Social Communication - This relates to your child’s ability to manage emotions, make and maintain friendships, perspective taking etc.

Service Delivery Preference *

Select all options that would suit

Clinic Visit

School Visit

Online (Zoom) Sessions

Availability

Please tick the boxes that indicate your availability for speech pathology services.

Monday - 9am-3pm

Monday - 3pm - 6pm

Tuesday - 9am - 3pm

Tuesday - 3pm - 6pm

Wednesday - 9am - 3pm

Wednesday - 3pm - 6pm

Thursday - 9am - 3pm

Thursday - 3pm - 6pm

Friday - 9am - 3pm

Friday - 3pm - 6pm