NEW CLIENT ENQUIRY FORM

Client Details and Contact Information

Client Name *

Date of Birth *

Parent/Guardian Name(s) *

Phone *

Email *

Preferred method of contact: *

PhoneEmailEither

Referral and Funding

How did you hear about us? *

Does the client have a current NDIS plan? *

YesNo

NDIS Number:

NDIS Plan Dates:

NDIS Funding Managed:

Self-ManagedPlan-Managed

If plan-managed, please provide details below:

Service Type and Availability

Services needed: *

Speech PathologyOccupational TherapyBothUnsure - would like to discuss

Type of service needed: *

Assessment & Report onlyAssessment & ongoing therapyUnsure

Preferred Appointment Times

Please select ALL the days and times that would work for appointments.

Please note: typically 'AM' is before 12pm, & 'PM' is after 12pm.

Monday

Tuesday

Wednesday

Thursday

Friday

I am flexible across days and times

Comments or specific preferences:

Are there any deadlines or timeframes we should be aware of? *

YesNo

(e.g. upcoming NDIS plan review, etc.)

Client Background (for triage purposes)

Brief reason for seeking therapy: *

Has the client seen a speech pathologist or occupational therapist before? *

YesNo

If yes, briefly outline when and where:

If you have any letters, reports, assessments or similar that are relevant please upload below. Alternatively you can email to hello@sunshinespeechalliedhealth.com.au.

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Is there anything else you would like to add?

I consent to Sunshine Speech & Allied Health collecting and storing this information for the purpose of contacting me regarding services *

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