Service 1 *

The service I am wishing to engage with: (select one)

Psychology

Speech Pathology

Service 2

I am also interested in:

No other service

Psychology

Speech Pathology

Telehealth

I'm wanting in-person appointments ONLY

I'm wanting Telehealth appointments ONLY

I'm interested in either/both formats of support

Speech Reason for Referral

NA - if not intending to engage with Speech services

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 participant 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

After school appointments *

I understand that there is a mental health crisis in Australia at this time, and that after school appointments are likely not possible.

I understand that after school appointments are unlikely.

How did you hear about us? *

Social Media

Website

Word of Mouth

Conference / Expo

Event

Other

Payment *

Please note, in order to secure your initial appointment, upfront payment is required. In the event the appointment is cancelled, and this is outside the cancellation period, third party transaction fees are deducted from the total fee refunded.

I understand

Children's Groups Programs

I have looked on the website at the children's group prgorams, and would like to be contacted when these become available.

Yes please!

No thank you.

Expression of Interest *

I understand that I will be placed on an expression of interest list and be sent an email in the coming weeks. We will be in touch when a position becomes available.

Yes, I understand.

ATT *

Animal Assisted Therapy - Canine

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.