Client Contact

Today's Date*

Client Name*

First Last

Client Date of Birth*

Parent/Guardian Name*

First Last

Parent/Guardian/Carer

Additional Parent / Guardian / Carer Name

First Last

Postal Address*

Street Address Address Line 2 Suburb State Post Code Country

Email*

Best Phone Contact*

Client History

Your Concerns - Please detail your reason for requesting appointment*

Does client attend child care, school, high school, uni or work*

If yes please list location location and days/ times of attendance

Does the client have a formal diagnoses of illness or disability*

If Yes, please detail full description below of date and diagnosis.

Date and description of formal diagnosis.

Does the client attend with other specialists or health professionals? Please detail, name, specialty, how long you have been attending with them.

Paediatrician, GP, Occupational Therapist, Psychologist, other Speech Language Pathologist?

Has hearing been tested

If yes, please advise date hearing checked and result

Please detail client's general interests

Please detail any comments or concerns below

I have read and agree to Rachel Wastell Speech Privacy Policy and waiver for providing information digitally.*

I agree and consent to Rachel Wastell Speech Privacy Policy.
I consent to the waiver in providing information digitally via Rachel Wastell Speech website.

Found here: https://rachelwastellspeech.com/cancellation-policy/ https://rachelwastellspeech.com/privacy-policy/