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SpeechEase Priority List Registration Form
Welcome to the Priority List registration for SpeechEase Speech Therapy.
Please complete our short security question before completing the rest of the form.
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* Indicates required question
Which SpeechEase Speech Therapy clinic are you enquiring about?
*
Mackay
Townsville
Mansfield
Primary Contact Person
Who should we contact about this registration and what are their contact details?
First Name
*
Your answer
Last Name
*
Your answer
Email Address
*
Your answer
Mobile Number
*
Your answer
Client Information
Tell us about the person who needs speech pathology supports.
Client's First Name
*
Your answer
Client's Last Name
*
Your answer
Client's Date of Birth
*
MM
/
DD
/
YYYY
Client's Gender
*
Female
Male
Nonbinary
Other:
Do you have a pre-existing relationship with SpeechEase?
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Yes
No
What area(s) does the client need speech pathology support with?
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Speech / Articulation - The person has difficulty pronouncing sounds and/or others find it hard to understand them.
Expressive Language - The person is non-verbal or is not using many words and/or is not putting together sentences and/or have difficulty expressing their message.
Receptive Language - The person has difficulty following directions and/or answering questions with the expected information.
Swallowing - The person has difficulty chewing and/or swallowing and is regularly choking, coughing or throat clearing when swallowing food and/or drinks
Food Aversions - The person eats less than 30 different types of foods and actively avoids foods of different texture, taste, colour or food group.
Fluency - The person stutters by repeating sounds, words or phrases and/or adds additional words into their sentence regularly (e.g. "um") and/or gets stuck either on a sound or not on a sound and struggles to finish their message.
Voice - The person's voice sounds scratchy, rough or tight and/or the person has trouble keeping their volume at a level loud enough to be heard and/or the person's voice cuts in and out when speaking.
Social Skills - The person has difficulty initiating interactions and/or taking turns and/or engaging in conversation with others.
Literacy - The person has difficulty reading and/or spelling.
Required
Of the options you selected above, what is the person's main concern?
*
Speech / Articulation
Expressive Language
Receptive Language
Swallowing
Food Aversions
Fluency
Voice
Social Skills
Literacy
Other:
When did you first notice difficulties with this?
*
Your answer
Goals for therapy
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What are you wanting to work towards? What would life be like if the client didn't have these difficulties?
Your answer
Does the client have a diagnosis or disability?
*
Yes
No
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