Test Part A Form - SpeechCare

Test New Booking Form Part A

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Referral Details - Step 1 of 5

This therapy booking request is for a *

Child (under 18yo)
Adult (over 18yo)

I am filling this form out (Child) *

as a Parent for my Child
as a Guardian for a Child in my care
as a Teacher/Admin referring a Student
to Refer a Client under 18yo

the Name (Adult)

I am filling this form out (Adult) *

to Refer a Client over 18yo
for Myself
on Behalf of an Adult

I am seeking services for (Adult) *

Speech Pathology in Clinic/Telehealth
Occupational Therapy in Clinic/Telehealth
Counselling in Clinic/Telehealth

I am seeking services for *

Speech Pathology at School
Inclusion Support at School
Speech Pathology in Clinic/Telehealth
Occupational Therapy in Clinic/Telehealth
Counselling in Clinic/Telehealth

Preferred Speechcare Location *

Speechcare Clinic in Bayside Wynnum QLD
Speechcare Clinic in Carina QLD
Speechcare Clinic in Daisy Hill QLD
Mobile | Bald Hill & Surrounds
Wherever I can get an appointment ASAP
Telehealth

Student is currently attending *

John Paul College
Moreton Bay Boys’ College
Moreton Bay College
St Joseph’s Primary School Kangaroo Point
Brisbane Adventist College
Other

School Name *

Referrer's Name: *

First

Last

Your Name: *

Your Email *

Workplace/School *

Referrer's Email *

Your Position *

Referrer's Phone *

How can we help? *

Speech difficulties (speech sounds, clarity)
Stuttering
Voice
Language - Understanding
Language - Expressing
Literacy (reading, writing)
Social Communication & Play
Swallowing | Mealtimes
Fine Motor Skills (e.g., handwriting, coordination)
Gross Motor Skills (e.g., balance, movement)
Sensory Processing
Daily Living Skills (e.g., dressing, feeding, routines)
Emotional Regulation
Behavioural Concerns
Anxiety | Worries
Social Skills & Friendships
Counselling | Emotional Support
Inclusion Support
Education and Learning Concerns
Assessments
Accent Reduction
Public Speaking
Neurological Communication Difficulties (e.g., stroke, brain injury, slurred speech)
Other

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Client's Full Name *

First

Last

Your Full Name *

First

Last

Preferred Name

Date of Birth *

Pronouns

Age *

Aboriginal or Torres Strait Islander? *

Aboriginal
Torres Strait Islander
Neither

Language other than English spoken at home? *

Yes
No
Not sure

If yes, please specify *

Is there a current diagnosis, illness or medical condition? *

Yes
No
Not sure
Waiting for Assessment or Results

Diagnosis/es *

Please write all speech, language, literacy, social communication disorders and diagnosis/es. Include expected/suspected or provisional diagnoses and assessment status if there is no diagnosis.

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Contact Details

We will use this information to send further details and booking information.

Parent/Guardian's Name: *

First

Last

Preferred Name

Pronouns

Phone *

Alternate Phone Number

Email *

Preferred Contact Method *

Email
Phone

Home Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Postal Address (leave blank if the same as home address)

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

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Is the Client covered by Private Insurance? *

Yes
No
Not sure

Do you have Private Insurance? *

Yes
No
Not sure

If yes, please specify *

Does the Client have NDIS funding for therapy? *

Yes
No
Not sure

Do you have NDIS funding for therapy? *

Yes
No
Not sure

If yes, please specify *

Self Managed
Plan Managed

NDIS Participant Number

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How did you hear about us? *

Local School
Google
GP/Specialist Referral
Family/Friends
Socials
Other

Please specify

Anything else we need to know?

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Email *

Test New Booking Form Part B – Child

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Child's Details - Step 1 of 17

Child's Name *

First

Last

Child's Age *

Under 3 years old
3-5 years old
6-12 years old
13+ years old

Child's Date of Birth *

Email *

Parent/Guardian's Name *

Phone *

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Emergency Contact Name *

Emergency Contact Number *

Relationship to Client *

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Please note a referral is not required to see our clinicians.

GP | Specialist's Name

GP | Specialist's Number

GP | Specialist's Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

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Siblings' Names, Ages & Diagnoses (if any)

Were there any difficulties during pregnancy or birth? *

If yes, please specify

Have there been any hospitalisations? *

If yes, please specify

Was your child late to achieve speech/language/play/friendship milestones? *

If yes, please specify

Were there any feeding difficulties during infancy? *

If yes, please specify

Is there is a history in the child's family of speech, language, feeding, social, communication or other difficulties? *

Yes
No
Not sure

If yes, please specify

Has your child’s hearing been tested? *

If yes, please give details of results

Is there a history of middle ear infections/known or suspected hearing loss? *

If yes, please specify

Is there a family history of:

Heart disease
High blood pressure
Asthma
Stroke
Diabetes
Hearing loss
Allergies (like hay fever)
Cognitive changes (like dementia)
Neurological conditions (like Parkinson's)
Digestive conditions (like reflux or ulcers)
Other conditions related to speech, language, literacy and communication.

Please specify

Relevant Medical Reports

Drag & Drop Files, Choose Files to Upload You can upload up to 5 files.

Please upload any relevant medical reports or email admin@speechcare.com.au before your appointment.

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Current Year Group *

Current School *

Current Teacher *

Does your child experience any difficulty relating to other children or adults? *

If yes, please specify

Has your child been assessed by a Speech Pathologist or received speech therapy? *

If yes, please specify

Has your child been assessed by another allied health professional (Psychologist, Physiotherapist, Occupational Therapist)? *

If yes, please specify

child Date a

Relevant Education Reports

Drag & Drop Files, Choose Files to Upload You can upload up to 5 files.

Please upload any relevant education or school reports or email admin@speechcare.com.au before your appointment.

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CHILD DEVELOPMENT MATRIX

Please rate the following experiences over the past 6 months.

1. Eating, Feeding & Mealtimes:

How many different foods can your child currently eat? *

0-5
6-12
13-20
More than 20

My child eats a range of foods *

Never
Rarely
Sometimes
Often
Always

My child is happy, regulated and will stay at the table for the duration of their meal *

Never
Rarely
Sometimes
Often
Always

My child appears to enjoy eating *

Never
Rarely
Sometimes
Often
Always

I feel worried or concerned about my child’s eating/mealtimes *

Never
Rarely
Sometimes
Often
Always

Level of impact on our daily life is *

No Impact
Low Impact
Moderate
High Impact
Very High Impact

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2. Sensory Processing:

My child transitions between activities smoothly *

Never
Rarely
Sometimes
Often
Always

My child easily tolerates a range of sensory experiences (e.g. loud noises, crowded places, clothing) *

Never
Rarely
Sometimes
Often
Always

Level of impact on our daily life is *

No Impact
Low Impact
Moderate
High Impact
Very High Impact

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3. Language (Understanding & Expressing):

My child can easily understand instructions/questions *

Never
Rarely
Sometimes
Often
Always

My child uses spoken language to get needs met *

Never
Rarely
Sometimes
Often
Always

My child uses spoken language to get information from others *

Never
Rarely
Sometimes
Often
Always

Level of impact on our daily life is *

No Impact
Low Impact
Moderate
High Impact
Very High Impact

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4. Speech (Sounds & Clarity):

My child is easy to understand *

Never
Rarely
Sometimes
Often
Always

Level of impact on our daily life is *

No Impact
Low Impact
Moderate
High Impact
Very High Impact

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5. Literacy & Learning (for school-aged children only):

My child can tell stories about their experiences

Never
Rarely
Sometimes
Often
Always

My child can have a go at most tasks at school with minimal distress

Never
Rarely
Sometimes
Often
Always

Reading is a strength for my child

Never
Rarely
Sometimes
Often
Always

Level of impact on our daily life is *

No Impact
Low Impact
Moderate
High Impact
Very High Impact

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6. Handwriting & Fine Motor:

My child can hold pencil and scissors well enough to complete tasks *

Never
Rarely
Sometimes
Often
Always

Level of impact on our daily life is *

No Impact
Low Impact
Moderate
High Impact
Very High Impact

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7. Sleep:

My child stays awake late into the night *

Never
Rarely
Sometimes
Often
Always

My child wakes frequently or early *

Never
Rarely
Sometimes
Often
Always

Level of impact on our daily life is *

No Impact
Low Impact
Moderate
High Impact
Very High Impact

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8. Self-Help & Daily Independence:

My child is independent or motivated with dressing/toileting/hygiene *

Never
Rarely
Sometimes
Often
Always

My child is happy to complete care routines (e.g. hair brushing) with prompting *

Never
Rarely
Sometimes
Often
Always

My child easily engages with morning/bedtime routine *

Never
Rarely
Sometimes
Often
Always

Level of impact on our daily life is *

No Impact
Low Impact
Moderate
High Impact
Very High Impact

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PARENT-CHILD INTERACTION SKILLS CONFIDENCE RATING SCALE

Preschool (3–5 years) - As a parent/guardian I am confident:

Following my child’s lead during play or activities

Not at all confident
A little confident
Somewhat confident
Confident
Very confident

Using simple, clear language my child can understand

Not at all confident
A little confident
Somewhat confident
Confident
Very confident

Giving my child enough time to respond or talk

Not at all confident
A little confident
Somewhat confident
Confident
Very confident

Using gestures, facial expressions, and tone to support communication

Not at all confident
A little confident
Somewhat confident
Confident
Very confident

Commenting on what my child is doing or saying rather than using questions to test

Not at all confident
A little confident
Somewhat confident
Confident
Very confident

Reading books with my child to encourage engagement and interaction

Not at all confident
A little confident
Somewhat confident
Confident
Very confident

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PARENT-CHILD INTERACTION SKILLS CONFIDENCE RATING SCALE

Primary (6-12 years) - As a parent/guardian I am confident:

Using age-appropriate, clear language my child can understand

Not at all confident
A little confident
Somewhat confident
Confident
Very confident

Using interaction styles that support positive communication

Not at all confident
A little confident
Somewhat confident
Confident
Very confident

Giving my child enough time to express ideas and thoughts

Not at all confident
A little confident
Somewhat confident
Confident
Very confident

Asking open-ended questions to encourage detailed responses (e.g., “What do you think?” or “How did that make you feel?”)

Not at all confident
A little confident
Somewhat confident
Confident
Very confident

Commenting on and expanding what my child says to model more complex sentences

Not at all confident
A little confident
Somewhat confident
Confident
Very confident

Encouraging my child to explain ideas, feelings, and opinions

Not at all confident
A little confident
Somewhat confident
Confident
Very confident

Using everyday routines or shared activities to practice new vocabulary or problem-solving

Not at all confident
A little confident
Somewhat confident
Confident
Very confident

Reading and discussing story content, characters, and themes together

Not at all confident
A little confident
Somewhat confident
Confident
Very confident

Encouraging reflection on daily experiences and feelings *

Not at all confident
A little confident
Somewhat confident
Confident
Very confident

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Anything else we need to know?

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CONSENT TO TREATMENT | CHILD INFORMATION

I understand that if I have any questions or concerns regarding my child’s treatment, I should discuss them with the Speech Pathologist before signing this consent.

I understand that at times, it is important for my child’s clinical information to be shared with other relevant Professionals, such as a GP, a referring Specialist, Teacher/Educator or an Allied Health Professional.

I understand that a minimum of 24 hours notice is required for appointment changes or cancellations and that those appointments cancelled or changed with less than 24 hours notice may incur a $115.00 fee.

I consent to my child's treatment by Speechcare.

I consent to the release of my child’s clinical information to relevant professionals if needed, with the understanding that I will be consulted before any information is shared.

The information I have provided is correct and complete.

Signature

Clear Signature

Today's Date *

CONSENT TO HEIDI: AI MEDICAL SCRIBE

Before we proceed with your appointment, we want to inform you about an important aspect of how we are now documenting our consultations.

We are now utilising a note taking tool called Heidi to accurately and efficiently capture the details of our discussions and the outcomes of our appointments.

Heidi ensures that we can focus more on our conversation and less on manual note taking, enhancing the quality of care you receive.

Your consent is crucial for us to use this technology. Please understand that your information will be handled with the utmost care, and Heidi’s use is aimed solely at improving your healthcare experience.

By signing this consent form, you are agreeing to allow your Clinician to use Heidi during this consultation and all future consultations.

Signature

Clear Signature

Today's Date *

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Enter your email address to receive the link via email. Alternatively, you can copy and save the link below.

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Email *

Test New Booking Form Part B – Adult

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Client Details - Step 1 of 13

Client Name *

First

Last

Date of Birth *

Email *

Age *

Phone *

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Emergency Contact Name *

Emergency Contact Number *

Relationship to Client *

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Please note a referral is not required to see our clinicians.

GP | Specialist's Name

GP | Specialist's Number

GP | Specialist's Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

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Have you recently been hospitalised or had any operations? *

If yes, please specify

Is there is a family history of speech, language, feeding, social, communication or other difficulties? *

Yes
No
Not sure

If yes, please specify

Is there a family history of:

Heart disease
High blood pressure
Asthma
Stroke
Diabetes
Hearing loss
Allergies (like hay fever)
Cognitive changes (like dementia)
Neurological conditions (like Parkinson's)
Digestive conditions (like reflux or ulcers)
Other conditions related to speech, language, literacy and communication.

If yes, please specify

Relevant Medical Reports

Drag & Drop Files, Choose Files to Upload You can upload up to 5 files.

Please upload any relevant medical reports or email admin@speechcare.com.au before your appointment.

Save and Resume Later

Have you been assessed by a Speech Pathologist? *

If yes, please specify

Have you been assessed by another Allied Health Professional (Psychologist, Physiotherapist, Occupational Therapist)? *

If yes, please specify

Relevant Reports

Drag & Drop Files, Choose Files to Upload You can upload up to 5 files.

Please upload any relevant reports or email admin@speechcare.com.au before your appointment.

Save and Resume Later

COMMUNICATION

How I communicate *

I speak in full sentences and communicate easily
I use short sentences or phrases
I use single words to communicate
I use AAC (e.g. device, PODD, signs, gestures, visuals)
Communication changes depending on the environment or situation
I use more than one language
Unsure about communication level
Other

Notes

I notice challenges or differences with *

Understanding instructions
Understanding feelings words or abstract ideas
Expressing needs or feelings
Finding the right words
Keeping conversations going
Understanding other people’s communication styles
Remembering what to say during conversations
None of these

Notes

Communication profile and/or diagnoses if known *

Autism / neurodivergent
Language disorder
Speech sound disorder
Intellectual or cognitive disability
Developmental delay
No diagnosis but I’m exploring possibilities
No diagnosis

Notes

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CONFIDENCE

How confident are you in each of these areas:

Understanding everyday instructions *

Not at all
Slightly
Somewhat
Mostly
Very Confident

Understanding other people’s feelings or emotions *

Not at all
Slightly
Somewhat
Mostly
Very Confident

Expressing needs and wants *

Not at all
Slightly
Somewhat
Mostly
Very Confident

Expressing feelings *

Not at all
Slightly
Somewhat
Mostly
Very Confident

Asking for help or clarification *

Not at all
Slightly
Somewhat
Mostly
Very Confident

Making and maintaining friendships *

Not at all
Slightly
Somewhat
Mostly
Very Confident

Joining in with others (e.g. conversations, activities) *

Not at all
Slightly
Somewhat
Mostly
Very Confident

Adapting to different communication styles or social expectations *

Not at all
Slightly
Somewhat
Mostly
Very Confident

Staying calm when things feel difficult *

Not at all
Slightly
Somewhat
Mostly
Very Confident

Managing big feelings (e.g. sadness, anxiety, anger, overwhelm) *

Not at all
Slightly
Somewhat
Mostly
Very Confident

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DAILY LIFE & SENSORY NEEDS

I notice differences or challenges with my *

Sensory needs (noise, touch, clothing, food textures, movement, etc.)
Fine motor tasks (buttons, cutlery, writing)
Balance or coordination
Organisation or planning
Sleep
Eating or feeding
Hygiene or self-care
Following routines
Safety awareness
Emotional regulation
None of these

Notes

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SOCIAL

Social situations that can be tricky for me *

School
Work
Community spaces
Family relationships
Friendships or romantic situations
I don’t find social situations tricky
Other

Notes

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RELATIONSHIPS, IDENTITY & WELLBEING

I would like support with: *

Understanding boundaries and consent
Navigating friendships, dating, or relationships
Talking about feelings or intimacy
Exploring identity (gender or sexuality)
Sexual health and safety
Feeling confident in relationships
Managing shame, anxiety, or confusion about sexual topics
Not applicable

Notes

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OTHER HEALTH SERVICES & SUPPORTS

Health or support services I currently work with or have worked with: *

Occupational Therapy
Psychology
Social work
Counselling
Physiotherapy
Dietician
Paediatrician / GP
Mental health services
School support / inclusion staff
Support workers
NDIS providers
None

HELP US MATCH YOU WITH THE RIGHT SUPPORT

The more we understand about you, the better we can tailor support and match you with the right therapist.

We know forms can sometimes feel overwhelming, so if you’d prefer, you can skip these questions for now and talk through them together during your first session.

Written questions *

Let's skip them - I’d prefer to discuss these questions with my therapist in our first session instead.
I'm happy to answer them now
I have someone to help me answer them now

What went well with previous services: (What worked for me? What felt safe, supportive, or helpful?)

What I liked or appreciated: (For example: pace, communication style, sensory setup, flexibility, visuals, co-regulation, etc.)

What didn’t work well or didn’t help: (Approaches, environments, communication styles, or expectations that were not supportive for me.)

Things that help me feel safe, understood, or comfortable:

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GOALS

What I want Speechcare to support me with:

a history What

Anything else you'd like us to know?

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CONSENT TO TREATMENT

I understand that if I have any questions or concerns regarding my treatment or treatment for my child, I should discuss them with the Counsellor before signing this consent.

I understand that at times, it is important for my (or my child's) clinical information to be shared with other relevant Professionals, such as a GP, a referring Specialist or an Allied Health Professional.

I consent to treatment, and I consent to the release of my clinical information to other relevant Professionals if required.

The information I have provided is correct and complete.

Signature

Clear Signature

Today's Date *

CONSENT TO HEIDI: AI MEDICAL SCRIBE

Before we proceed with your appointment, we want to inform you about an important aspect of how we are now documenting our consultations.

We are now utilising a note taking tool called Heidi to accurately and efficiently capture the details of our discussions and the outcomes of our appointments.

Heidi ensures that we can focus more on our conversation and less on manual note taking, enhancing the quality of care you receive.

By signing this consent form, you are agreeing to allow your Clinician to use Heidi during this consultation and all future consultations.

Signature

Clear Signature

Today's Date *

Save and Resume Later

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Your form entry has been saved and a unique link has been created which you can access to resume this form.

Enter your email address to receive the link via email. Alternatively, you can copy and save the link below.

Please note, this link should not be shared and will expire in 30 days, afterwards your form entry will be deleted.

Copy Link

Email *

Test New Booking Form Part B – Inclusion Support

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Student Details - Step 1 of 9

Student's Name *

First

Last

Student's Date of Birth *

Email *

Parent/Guardian's Name *

Phone *

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Emergency Contact Name *

Emergency Contact Email *

Relationship to Student *

Emergency Contact Phone *

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Is there is a family history of speech, language, feeding, social, communication or other difficulties? *

Yes
No
Not sure

Please specify

Were there any delays in reaching speech/language/play/friendship milestones? *

Yes
No
Not sure

Please specify

Has the student's hearing been tested? *

Yes
No
Not sure

Please tell us about the results

Is there a history of middle ear infections/known or suspected hearing loss? *

Yes
No
Not sure

Please specify

Relevant Medical Reports

Drag & Drop Files, Choose Files to Upload You can upload up to 5 files.

Please upload any relevant medical reports or email admin@speechcare.com.au before your appointment.

Save and Resume Later

Has the student been assessed by a Health Professional? *

Yes
No
On wait list

This can include doctors, paediatricians, speech pathologists, psychologists, OTs etc

Please specify

Is or has the student received ongoing therapy from a Health Professional? *

Yes
No
On wait list

Please specify

Relevant Therapy Reports

Drag & Drop Files, Choose Files to Upload You can upload up to 5 files.

Please upload any relevant reports or email admin@speechcare.com.au before your appointment.

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Areas of Concern *

Learning (literacy, numeracy, processing)
Behaviour / emotional regulation
Social skills / friendships
Communication (speech/language)
Sensory needs
Attention / executive functioning
Physical / motor skills
School refusal / anxiety

Tell us about your biggest concerns right now *

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Student's Current School or Education Centre *

Student's Year Group *

Classroom Type *

Mainstream
Support Unit
Flexible Learning
Other

Please Specify *

Attendance Patterns *

Fulltime
Parttime
School attendance difficulties/school can't
Irregular attendance

Has the school been informed of relevant diagnoses/difficulties? *

Yes
No
Not sure

Student's from with

Does the student have an existing Individualised Learning Plan (IEP/PLP)? *

Yes
No
Not sure

If yes, can you please upload below or email us a copy to admin@speechcare.com.au

Drag & Drop Files, Choose Files to Upload You can upload up to 5 files.

Please upload any relevant documents or email admin@speechcare.com.au before your appointment.

If yes, when was the IEP/PLP last reviewed?

Current School-Based Supports (if any)

External supports (NDIS, therapy, tutoring)

Adjustments currently used (Aide time, modified work)

How concerned are you about the student needing inclusion support at school? *

Urgent (risk of school expulsion)
Important (approaching crisis)
Needed (parent and/or school are requesting help)
Support would be helpful
Other

Please specify *

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What does the student enjoy? *

What are their strengths? *

What works well for them? *

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What are you hoping to achieve through inclusion support? *

Do you need support with *

Communicating with the school
Attending meetings
Understanding rights/policies
Reviewing plans (IEP/PLP)
Other

Please specify *

Have there been any challenges with the school?

Anything else we need to know?

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CONSENT TO TREATMENT | CHILD INFORMATION

By completing this form, you consent to the collection and sharing of relevant information between Speechcare, your child’s educators, and other involved professionals for the purpose of planning and supporting your child’s inclusion.

This information will be used to guide appropriate adjustments, strategies, and supports within the learning environment.

Your information will be handled confidentially and only shared with your permission or as required to support your child.

Signature *

Clear Signature

Today's Date *

CONSENT TO HEIDI: AI MEDICAL SCRIBE

Before we proceed with your appointment, we want to inform you about an important aspect of how we are now documenting our consultations.

We are now utilising a note taking tool called Heidi to accurately and efficiently capture the details of our discussions and the outcomes of our appointments.

Heidi ensures that we can focus more on our conversation and less on manual note taking, enhancing the quality of care you receive.

By signing this consent form, you are agreeing to allow your Clinician to use Heidi during this consultation and all future consultations.

Signature *

Clear Signature

Today's Date *

Save and Resume Later

Go Back

Your form entry has been saved and a unique link has been created which you can access to resume this form.

Enter your email address to receive the link via email. Alternatively, you can copy and save the link below.

Please note, this link should not be shared and will expire in 30 days, afterwards your form entry will be deleted.

Copy Link

Email *