Speech Pathology Pre-Booking Form

REFERRAL INFORMATION

Date of Referral

Referral Type

REFERRER DETAILS

Referrer's Name

First

Last

Referrer's Email

Referrer's Phone

BEST CONTACT FOR APPOINTMENTS

Contact's Name

First

Last

Contact's Email

Contact's Phone

PATIENT DETAILS

Patient Name

First

Last

Date of Birth

Patient Carer / Guardian

Phone

Email

Please select your preferred method of contact:

SMS
Phone Call
E-mail

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Diagnosis / Medical History:

APPOINTMENT PREFERENCES

Appointment Preference Days

Appointment Preference Times

Appointment Preference Types

In-clinic
Home-visit
School Visit
Telehealth

NDIS DETAILS (leave blank if not relevant)

NDIS number

Plan Start Date

Plan End Date

NDIS Types

Self-Managed
Plan Managed
Agency Managed

Plan Manager

TRIAGE QUESTIONS

What services are you currently accessing? (please provide details)

Occupational Therapy

Physiotherapy

Podiatry

Psychology

Speech Therapy

Dietitian

Exercise Physiology

reading Date patient

Other

Does the patient have a history of exhibiting behaviours that could potentialy harm themselves or others?

Yes
No

If yes, please provide details:

Is the patient able to effectively communicate their needs?

Yes
No

If no, please provide details:

Is the patient using a communication device or is the patient likely to require a communication device?

Yes
No

If yes, please provide:

Is the patient able to eat and drink safely?

Yes
No

If no, please provide details of difficulty and date of their last swallow assessment:

DETAILS OF SERVICE REQUEST

Does the patient require:

Assessment
Ongoing Therapy

Does the patient require support with their speech? E.g. Their articulation, the sounds they use in their words

Yes
No

If yes, please provide details:

Does the patient require support with their language? E.g. Understanding what is said to them, their vocabulary, the length/structure of their sentences

Yes
No

If yes, please provide details:

Does the patient require support with their reading and writing?

Yes
No

If yes, please provide details:

Does the patient require support with stuttering?

Yes
No

If yes, please provide details:

Does the patient require support with their voice? E.g. Pain in throat, difficulties talking at different volumes or for longer periods of time

Yes
No

If yes, please provide details:

Does the patient require support with their eating and drinking?

Yes
No

If yes, please provide details:

If seeking assessment what is the purpose of the assessment? E.g. Seeking diagnosis or access to NDIS funding (leave blank if not relevant)

Will a report be required explaining the assessment results?

Yes
No

Provide Extra Details of Difficulties

CANCELLATION POLICY

At Downs Physiotherapy we understand that unexpected things can prevent you from attending your appointment. A cancellation fee will be charged at 100% of the agreed support price, if you:

Have given the provider less than two (2) clear business days' notice for cancellation of a support; or
Fail to show up for a scheduled support withing a reasonable time (e.g., in the event the support is being delivered in the clinic where the provider is located); or
Are not present at the agreed place within a reasonable time when the provider is travelling to deliver the support (e.g., in the event the provider provides the support as a home visit or a third-party location)

If you need to cancel an appointment, please make sure you contact the clinic directly by phone on 46334411

I understand the cancellation policy as outlined above

Yes

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Speech Pathology

Speech Pathologist