Paediatric Assessment Registration Form

To make an appointment for your child, please fill out all required fields on the paediatric assessment registration form below, and sign the form before submitting. We will be in touch soon after we receive your child’s registration form to arrange a suitable appointment time.

Family Details

One parent/guardian's full set of details must be filled out on the form. If child is living with both parents/guardians, full details of both parents/guardians are required.
Best contact number
Best contact number
e.g. Rebecca Bink 3, Elijah Bink 6, David Bink 10 (NIL for none)
e.g. separated, divorced etc.

Communication History

Please select all answers that apply
Please select all answers that apply
Provide your best estimate. e.g. 50%
Please select all answers that apply
List all methods. e.g. talks, grunts, points, uses gestures or a sibling to talk to him/her.
e.g. coughing, choking or gagging?

Medical History

Please select all that apply
if none answer 'NIL'

Assessments

Select one of these options.

Consent

To give consent for the following, check the tick boxes below
Please tick all the checkboxes you agree with.
If yes, no additional cost applies.

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
* Educational assessment with report (no speech/language) - $750

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 will be offered an appointment as soon as possible.

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

e.g. 24/1/2021
eg, mother, father, guardian
Please sign here.
=

Pin It on Pinterest