Sydney Speech Clinic Paediatric Enquiry Form
Thank you for your enquiry. Please complete the information on this form to register your interest in Speech and/or Occupational Therapy. Please also send any relevant reports and documents to
info@sydneyspeechclinic.com.au
.
* Required
Parent Full Name
*
Your answer
Phone Number
*
Your answer
Email Address
*
Your answer
Postcode
*
Your answer
Child's Full Name
*
Your answer
Child's Date of Birth
*
MM
/
DD
/
YYYY
Please explain your current concerns and what or who prompted you to seek therapy
*
Your answer
Does your child have a diagnosis or disability?
Your answer
Which type of therapy are you seeking?
*
Speech Therapy
Occupational Therapy
Not Sure
Required
Is there anything else you would like us to know?
Your answer
Are there any days/times you cannot make it to the clinic? (Please note that we are currently experiencing high demand for our services. We are sorry to advise that waiting times might apply for some services but if you are flexible it is easier for us to meet your needs sooner.)
Your answer
What type of funding do you have?
*
Private Payer - Pay myself (optional private health/medicare CDM plan)
NDIS (National Disability Insurance Scheme)
Other:
How did you find out about Sydney Speech Clinic?
*
Google
Other Internet Search Engine
Doctor
Teacher
Friend
In The Cove
Facebook/Instagram
Walked Past
Screening
Community Health
Other Health Professional
Previous Client
Other:
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