Better Start Educational Services Referral Form

Request for Speech Pathology

Child's Name Required

Male / Female Required

Parent / Guardian Name Required

Date of Birth Required

Address Required

Phone

Home

Mobile

Email (Invoices and receipts are sent via email) Required

Centre / School

Year Level

Attendance

Teacher(s) Name(s)

Parent / Guardian Consent

I understand that I will receive an invoice after the consultation and payment terms are strictly 7 days. I have been informed of the fees charged by Better Start and I agree to pay those fees when due. I understand that late fees will be charged for overdue accounts. I understand that 24 hours’ notice is required to cancel appointments, otherwise a fee will apply. I understand that Better Start reserves the right to require my credit card details in advance as a pre-condition to the performance of any services for my child. I hereby authorise Better Start to process any payments due to Better Start by credit card if such payments remain outstanding for more than 7 days. This authority is irrevocable.

Consent Requirements Required

I give consent for my child to be seen by Better Start.

I understand that my child may be withdrawn from class for assessment/therapy services.

I give consent for Better Start to access information regarding previous professional reports.

I give consent for Better Start to take video/audio of my child for the sole purpose of informing therapy and will only be shared with parent/guardian.

I understand that information, including relevant medical information, will be shared on a strictly confidential basis with staff working with my child.

I understand that this consent remains valid until withdrawn by parent/guardian.

I understand that I will receive an invoice after the consultation and payment terms are strictly 7 days. I have been informed of the fees charged by Better Start and I agree to pay those fees when due. I understand that late fees will be charged for overdue accounts. I understand that 24 hours notice is required to cancel appointments, otherwise a fee will apply. I understand that Better Start reserves the right to require my credit card details in advance as a pre-condition to the performance of any services for my child. I hereby authorise Better Start to process any payments due to Better Start by credit card if such payments remain outstanding for more than 7 days. This authority is irrevocable.

Parent / Guardian name/ sign Required

Date Required

Relevant Information

Please complete the following information.

Has your child had previous Speech Pathology, Psychology and/or Occupational Therapy support? If yes, who with and when?

Has your child seen a paediatrician regarding your current concerns? Who? When?

Has your child’s hearing been tested? If yes, when and what were the results?

Has your child’s vision been tested? If yes, when and what were the results?

Are any languages other than English spoken at home?

Indicate the areas in which you are concerned:

General development & progress

Listening & attention (sustaining attention to tasks, focusing)

Speech development (using clear speech)

Language expression (using words in sentences, vocabulary)

Language comprehension (listening, understanding, following instructions)

Stuttering

Literacy skills (reading, spelling, writing)

Behaviour

Other

Briefly describe your main concerns.

Does your child have a formal diagnosis? i.e. Autism Spectrum Disorder, Downs Syndrome, Global Developmental Delay etc?

Does your child have eligibility for Commonwealth funding under:

NDIS (National Disability Insurance Scheme)

Medicare Plan

If you answered NDIS (National Disability Insurance Scheme) please complete the following three fields:

Participant Number:

End Date of Current Plan:

Is the plan

Please provide any additional details:

Is your child a subject of any court orders?

Yes

How did you hear about Better Start Education Services?

If other please specify

Online Referral Form for Adelaide Speech Pathology Services

Request for Speech Pathology

Phone

Parent / Guardian Consent

Relevant Information

Fun and interactive therapy for your child

Therapy for language and speech disorders

Professional services with experienced therapists

Visiting your home or school

Support for dyslexia, stuttering and children with Autism

Approved providers

Speech Pathology across Adelaide