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
Parent Full Name
Child's Full Name
Child's Date of Birth
Please explain your current concerns and what or who prompted you to seek therapy
Does your child have a diagnosis or disability?
Which type of therapy are you seeking?
Is there anything else you would like us to know?
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.)
What type of funding do you have?
Private Payer - Pay myself (optional private health/medicare CDM plan)
NDIS (National Disability Insurance Scheme)
How did you find out about Sydney Speech Clinic?
Other Internet Search Engine
In The Cove
Other Health Professional
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This form was created inside of Sydney Speech Clinic.