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Book an Appointment

Thank you for your interest in SLP Therapy & Me!

Completing this form helps us understand your needs, funding, availability and any supports that may be required during appointments. This is not a commitment to services and does not guarantee a booking. The information provided helps us determine whether our service is a suitable fit and allows us to respond with relevant information about service options, pricing and availability.

Client Interest Form

Your Information

Name of Person Completing Form*

Your Relationship to Client*

Client Information

Client's First Name*

Client's Last Name*

Date of Birth*

Day

Month

Year

Address*

Contact Information

Phone for Contact*

Email for Contact*

What would you/your child like support with?

Speech sounds

Language

Literacy

Social communication

Stuttering

Feeding

Orofacial myofunctional therapy

AAC

Voice

Not sure / other

Tell us a bit more about what prompted you to get in touch.

Please share anything you think would be helpful for us to know.

Does the client have any diagnoses or developmental conditions that may be relevant to their speech pathology support?

You are welcome to include any diagnoses or conditions you feel are relevant.

How does the client currently communicate?

Conversation / sentences

Short phrases

Single words

Gestures / body language

Signs

AAC / communication device

Not sure / other

If you're not sure, please briefly describe the client's current communication skills.

Does the client require additional support in any of the following areas?

Attention and engagement

Understanding instructions or expectations

Transitions or changes in activity

Emotional regulation

Sensory needs

Staying in the therapy area / safety awareness

Personal care

Communicating wants and needs

No additional support that I'm aware of

Other

If you selected 'other', please briefly describe below.

Are there any behaviours or safety considerations we should know about when planning appointments?

Select from below*

Please tell us a little more about the behaviours or safety considerations and what usually helps.

Is there anything that would help the client feel comfortable, safe and able to participate during an appointment?

Optional

Funding

Do you/the client currently have NDIS funding?*

If you have/the client has NDIS funding, how is it managed?*

Appointment Preferences

Please list what days and times are preferable for Speech Pathology appointments, including whether school/preschool visits are an option.

Alternatively, please list what days and times are not suitable for appointments.

*

How did you hear about us?

Working Hours

Monday-Friday: 8am - 6pm

Saturday: closed

Sunday: closed

Email: info@slptherapyandme.com

Have any questions? Ask here

First name*

Last name*

Email*

Add your message here*

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