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Application for Assistance through the Low Income Card
Please complete the form to apply for consideration of receiving services for your child through the Low Income Card at a reduced fee. If you have any questions, please contact us on 9455 3927.
Today's Date *
Child's full name *
Child's date of birth *
Your full name *
Your relationship with the child *
Your best contact phone number *
Your best contact email address *
When does your Low Income Card expire? *
What is your main concern about your child? *
Are there any other concerns?
Have you been to see a Speech pathologist before? *
If you have seen a Speech Pathologist before, who did you see? For how long did you attend? Do you have any reports available?
Have you seen an Occupational Therapist for your child? *
Have you seen a Paediatrician for your child? *
Will you be able to attend therapy sessions at our clinic? *
Would you be able to attend weekly therapy sessions which are 30 minutes in length? *
Are you able to afford the current therapy fee of $36.20 per session? *
Do you agree to value each appointment by attending on time and having competed all the necessary homework? *
Do you agree to let us know with a minimum 24 hours notice if you are unable to attend an appointment? *
Do you understand that if 24hours notice is NOT provided, the non-attendance fee (which is the full price of the session + GST) needs to be paid before further sessions are provided? *
Do you understand that you need to attend a minimum 80% of booked appointments to ensure the best outcomes from the therapy provided? *
Thankyou for completing this form. We will be in touch with you shortly about your child and the services that we can provide them. If there is anything else you would like to tell us, please do so below.
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