Intake

REFERRAL

Name of person completing this form: *

If you are not the client, what is your relationship to the client?

If you are a support coordinator, please provide your phone number and email address:

Details:

CLIENT DETAILS

First name: *

Last Name: *

Preferred name (optional):

Date of birth *

Gender: *

Pronoun (optional):

Home address:

Street number and name: *

Suburb: *

State: *

Postcode: *

Service address (if services are to be conducted somewhere other than home or in clinic):

Contact name for appointments (if not the client):

Contact phone number for appointments: *

Contact email for appointments: *

Who will be signing all documents and the consent forms? *

ClientPerson responsible / Guardian / Nominee (outlined below)Client is under Public Guardian

ALTERNATIVE CONTACT

If the client needs another person's support to understand information and sign consent forms, please provide details of the Person Responsible for consent below:

If the client can sign consent for themselves, we still appreciate you giving details of another person we can call in case of emergency.

Choose all options that apply: *

Person Responsible / NomineeGuardianEmergency Contact

Name: *

Relationship: *

Phone: *

Email:

FUNDING

Please advise how this service will be funded: *

NDISLifetime Care and Support Scheme (approval letter required)Department of Veterans Affairs / DVA (Dr D904 referral required)Self-paying / Private health insuranceMedicare CDM subsidised (Medicare Form from Dr required)Aged Care PackageDisability Support for Older Australians (DSOA)Other

Details: *

Email address for Invoices (if NDIS agency managed, add: admin@wollongongspeech.com.au): *

If you are self-paying, do you have a pension card?

YesNo

If you are NDIS funded, please provide your NDIS billing information:

Self-Managed (Wollongong Speech Pathology will send an invoice to the participant or their Nominee to pay)Agency-Managed (Wollongong Speech Pathology will claim payment directly from the NDIA using the provider portal)Plan-Managed (Wollongong Speech Pathology will claim payment from your Registered Plan Manager - please provide more details below)

Plan Manager name (if relevant):

NDIS Participant number:

NDIS plan start date:

NDIS plan end date:

Speech pathology budget including details of funding periods (if known):

DVA Number (if applicable):

Aged Care Package Details (if applicable) - company, contact person, contact number:

DSOA Details (if applicable) - company, contact person, contact number:

REFERRAL INFORMATION

It is up to you how much information you provide below, however the more information you give us, the better we can process your referral and allocate a suitable speech pathologist.

Details:

Please provide further details on why speech pathology is required (or your goals for the service): *

Relevant medical history or diagnosis: *

Appointment Location: *

In Clinic (3/185 Berkeley Road, Unanderra NSW 2526)HomeOther

Details: *

We often run different group therapy programs throughout the year. Are you interested in group therapy? *

YesNoUnsure

History of speech pathology? *

YesNo

Important cultural or religious factors we should know about:

Interpreter required? If yes, provide details.

CLINICAL RISK SCREENING

The safety of our clients and staff is important to us. Please answer the following standard set of questions.

Does the person have a history of high-level infection (e.g. MRSA, CRE)? *

YesNo

Does the person have a history of falls? *

YesNo

Does the person have a history of seizures? *

YesNo

Is there any risk of aggression or violence during service delivery? *

YesNo

Does this person have a Behaviour Support Plan? *

YesNo

Might anyone at the service location be under the influence of alcohol or drugs during service delivery? *

YesNo

Are there any unrestrained, dangerous or aggressive pets at the service location? *

YesNo

Is the service location remote, or are there any access issues to the service location? *

YesNo

Are there issues with mobile phone coverage at the service location? *

YesNo

Comments:

OTHER

Please provide any other information you think will be useful: