Name of Client

First Name

Last Name

Is the client of Aboriginal or Torres Strait Islander origin?

Yes

No

Unsure

Type of Enquiry:

Capacity and Waitlist

Communication Difficulties

Swallowing Difficulties

Group Treatments

Assistive Technology

NDIS or Funding

Staff Education & Training

Preferred Day for Consultation

We will try our best to accomodate your schedule:

Monday

Tuesday

Wednesday

Thursday

NDIS Funding Mangement *

Please note we are only able to accept referrals from self or plan managed participants at this time.

Self-Managed

Plan-Managed

Telehealth Requirements *

Please note that all consultations are completed via telehealth. If you/the client does not have access to these requirements, do not hesitate to reach out and we can help to ensure your access to support is achieved. Confirm your/the clients access to the following:

Internet Connection

A tablet, computer or smartphone with microphone and camera access

If you/the client are unable to set up the session, assistance from a family/staff/support worker is available.

A quiet environment to conduct the sessions in

Form completed by: *

First Name

Last Name