Service *

I am wishing to engage with:

A psychologist for this assessment

A speech and language pathologist for this assessment

Telehealth *

I'm interested in in-person appointments ONLY

I'm interested in Telehealth appointments ONLY

I'm interested in either / both formats

Speech Reason for Referral

NA if not wishing to engage with speech for the purpose of this assessment

Speaking: verbal expression difficulties

Understanding: comprehension difficulties

Social communication difficulties

Late talker

General difficulties expressing thoughts and/or understanding language

Client's Name *

First Name

Last Name

Enquirer's Name

First Name

Last Name

Phone number *

(###)

###

####

Client's Date of Birth *

MM

DD

YYYY

Client's Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Please tell us which type of allied health / therapy services the client has previously accessed. *

Occupational Therapy

Speech Pathology

Psychology

Physiotherapy

None of the above

Have not accessed

Will you be accessing With You services under a Mental Health Care Plan? *

Yes

No

Payment

Please note, in order to secure your initial appointment, upfront payment is required.

I understand

Acknowledgement of in-school time appointments *

I understand that it in unlikely that after school appointments are appropriate for assessment/ available.

Yes, I acknowledge that after-school appointments are unlikely to be available

AAT *

Animal Assisted Therapy- Canines

I understand that some practitioners at the practice have canines as part of their therapy process, and that it is likely I may encounter them. I can let admin know if there is a concern.

How did you hear about us? *

Social Media

Website

Word of Mouth

Conference / Expo

Event

Other