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Speech with Rhi and Friends Waitlist Intake Form

Please complete this form in order to join our waitlist.

How are you looking to access our services? *NDIS fundingPrivately funding

NDIS

What is the participant's full name? *

What is the participant's date of birth? *

How does the participant identify? *MaleFemaleGender diverse (please provide additional information below)

Please specify

What is the participant's residential address? *

What is the participant's postal address? If the same as residential, please write 'as above' *

Does the participant identify as Indigenous?AboriginalTorres Strait IslanderBothNeitherOther (please specify)Please specify

Would you like to provide any additional information regarding the participants cultural background?

Does this participant have any relevant diagnoses? *

Does the participant have any allergies? *

Parent/Guardian Details

What is the parent/guardian's full name? *

Relationship to child? *

What is the parent/guardian's residential address? *

What is the parent/guardian's postal address? *

What is parent/guardian's email address?? *

What is the parent/guardian's phone number?

NDIS Plan/Funding Information

This participant will be utilising the following funding models *NDIS Plan ManagedNDIS Self Managed

What is the Plan Manager's Business Name? *

What is the Plan Manager's email address? *

What is the Plan Manager's phone number?

What is the participant's NDIS Plan Number? *

What are the participant's NDIS plan's start and end dates? *

Is this participant accessing any other therapies? *

Additional Information

Please use this section to provide us with information about the participant that you would like us to be aware of.

Is there anything else we should know about the participant?

Booking an Intake Appointment

Please specify ALL appointment types you are open to accepting: *Clinic appointments (Ningi QLD)Telehealth appointments (through Zoom)Home visit appointmentsSchool or daycare visit appointments

Please upload a copy of the participant's NDIS plan in its entirety so we can develop a personalised schedule of supports for the participant that ensures no overspending with respect to plan periods and the participants access to other therapies etc. A copy of this plan will be required before the intake appointment can take place. If you would prefer, please feel free to email it to us on admin@speechwithrhi.com.au

Drag and Drop (or) Choose Files

Main Concerns & Goals

Please provide specific details about your concerns and goals for speech therapy

What are you looking to improve? *Please provide details of the aboveReceptive Language (listening & understanding)Expressive Language (conveying thoughts, needs and feelings)Speech Skills/Speech SoundsSocial/Emotional SkillsReading and Writing SkillsAssessment (Language, literacy, speech sounds, ADOS and ADHD assessmentsOther - Please provide details of the above

Private Funding

What is the participant's full name? *

What is the participant's date of birth? *

How does the participant identify? *MaleFemaleGender diverse (please provide additional information below)

Please specify

What is the participant's residential address? *

What is the participant's postal address? If the same as residential, please write 'as above' *

Does the participant identify as Indigenous?AboriginalTorres Strait IslanderBothNeitherOther (please specify)Please specify

Does this participant have any relevant diagnoses? *

Does the participant have any allergies? *

Main Concerns & Goals

Please provide specific details about your concerns and goals for speech therapy

What are you looking to improve? *Receptive Language (listening & understanding)Expressive Language (conveying thoughts, needs and feelings)Speech Skills/Speech SoundsSocial/Emotional SkillsReading and Writing SkillsAssessment (Language, literacy, speech sounds, ADOS and ADHD assessmentsOther - Please provide details of the above

Parent/Guardian Details

What is the parent/guardian's full name? *

Relationship to child? *

What is the parent/guardian's residential address? *

What is the parent/guardian's postal address? *

What is parent/guardian's email address? *

What is the parent/guardian's phone number?

Funding Information

Are you planning on using any of the following to support your access to Speech Pathology services? *Private Health InsuranceMedicare Plan from GP (known as CDMP or ECP)Medicare Plan from Paediatrician (Medicare 135)Brokerage FundingNone of the above, we will be paying privately

If you opted to use private health can you please provide us the code that is required for your health fund to make a claim. If not please just write NA *

Is this child accessing any other therapies? *YesNoI'd rather not say

Additional Information

Is there anything else we should know about the participant? *

Appointments

Please specify ALL appointment types you are open to accepting:Select all that applyClinic appointments (Ningi QLD)Telehealth appointments (through Zoom)Home visit appointmentsSchool or daycare visit appointments

Consent *

I confirm that above information I have provided is true, complete and accurate.

Consent *

I give consent for Speech with Rhi and Friends to contact me via phone, email, or SMS regarding therapy appointments.

Consent *

I agree that if I do not return contact from the Speech with Rhi &
Friends team, my child’s details will not be retained on the waitlist.

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Speech with Rhi and Friends Enquiry Form

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