Adult Assessment Registration Form

To make an appointment, please fill out all required fields on the adult assessment registration form below and sign the form before submitting. We will contact you shortly after the receipt of the form to arrange your appointment.

Best contact number
Name and contact number
Tell us how you are related to your next of kin. e.g. cousin, brother, sister, aunt, parent.

Personal Details

Communication History

Medical History

if none answer 'NIL'

Assessments

SPEECH- the way words are spoken and the volume and clarity of speech and sounds. LANGUAGE - using and understanding words. FLUENCY - there are concerns regarding stuttering.

Consent

To give consent for the following, check the tick boxes below

Terms of Service Agreement

1. The consultation is for assessment only - no ongoing therapy will be offered or provided.
2. Payment is due at the time of consultation - EFTPOS or electronic transfer only.
3. Current fee for professional services are:

* Speech and voice assessment with written report - $400
* Language or fluency assessment with written report - $400
* Speech, voice and language assessment with written report - $600

4. Payment is the responsibility of the person making the appointment - invoices will not be issued to the NDIS, insurance companies or other third parties.
5. Cancellation of a scheduled appointment requires 48 hours notice. Cancellations received within 48 hours of the scheduled start time will incur a 50 percent cancellation fee. Appointment no-shows will incur a 100 percent cancellation fee. Please refer to our Cancellation Policy for further information.
6. Mobile phones are to be turned off during the consultation.
7. Upon receipt of this form, you will be notified and offered an appointment.

By signing below I state that I have read, and agree to, the above 'Terms of Service' agreement.

e.g. 24/1/2021
Please sign here.
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