New client forms

Prior to your initial appointment, we request all clients complete relative documentation to support the provision of individualised therapeutic supports. Please follow the instructions below and complete all relevant forms. Every client is required to have completed: a). Case History Form, and b). Service Agreement.

Once you have filled out the appropriate forms, click “Submit” which will provide our team with a copy. Please reach out via
0487544125 or hello@sunshinespeechalliedhealth.com.au if you have any questions.

Form 01.

Speech Pathology - Case History Form (Adult)

Speech Pathology Form (Adult)

Speech Pathology new client case history form (adult).

Purpose of the Case History Form

Collect the information required to accurately assess your communication and/or swallowing status. Collect the information to contribute to an ethical and evidence-based Treatment Plan. The information you provide is considered ‘health information’ under law. The information you provide is confidential and is stored securely, consistent with our Privacy Policy. Please fill out this questionnaire as fully as you can. We appreciate that you have likely answered multiple similar questions with other health professionals. Case history is an important part of our intake process and helps us to provide quality person-centred support.

Client name

First Name

Last Name

Client address

Client phone number

(###)

###

####

Funding details

NDIS

Private

(if with NDIS) is it:

Plan managed

Self managed

If plan managed provide these details

Company: Contact Name: Contact Phone: Contact Email:

Communication status

Do you currently use any of the following?

Interpreter (signed or spoken language) Hearing or listening supports (e.g. hearing aids, visual supports, etc.) Speech or communication supports (e.g. speech generating device, voice amplifier, iPad, assistive technology, etc.) Reading supports (e.g. reading assistance, screen reader, etc.) None of the above

Do you experience any of the following?

Difficulty expressing thoughts? Difficulty being understood by others? Difficulty understanding what others are saying to you? Difficulties with memory, attention, or concentration? Difficulties with reading or writing? Difficulties with social interaction or conversation? Stuttering and fluency difficulties? Breathy, hoarse, soft, or other concerns with voice? Self-conscious or other concerns around pronunciation? None of the above

Swallowing and meal time information

Do you experience any of the following?

Difficulties chewing food? Difficulties managing liquids? Coughing during and/or after eating or drinking? Choking on food and/or drink? Difficulties clearing food and/or liquid from mouth? Recurrent and/or unexplained chest infections? None of the above

Are you currently on a modified food and/or liquid diet?

Do you currently use any other food or mealtime supports? (e.g. supportive seating, adjusted utensils, swallow strategies, etc.)

Family & Social History

What language(s) do you speak at home?:

Where do you live?

Who do you live with?

Do any other close relatives have, or have a history of, difficulties with language, speech, reading, or spelling?

Are your concerns affecting your family/home life?:

Are your concerns affecting your ability to socialise or engage with others outside the home?

Are you currently working?

Are your concerns affecting your job performance?

Health history

Do you currently, or have you ever, experienced any of the following?

Allergies Reflux/GERD Snoring or sleep condition(s) Asthma, bronchitis, COPD Epilepsy or any seizures Head injury (including concussion) Meningitis Stroke Cancer Cleft lip and/or palate Hearing loss or impairment Psychological condition(s) (e.g. anxiety, depression, bipolar disorder, schizophrenia, etc.) Neurological condition(s) (e.g. MS, Huntington’s, Parkinson’s, etc.) Vocal polyps, nodules, or other voice-related condition(s) None of the above

Additional information

Is there any other information you wish to provide about yourself, your history, your concerns, or which will help us provide a quality, person-centred service?:

Please ensure this form is completed and returned at least one (1) business day PRIOR to your initial appointment to ensure your responses are reviewed.

Form 03.

Service Agreement - Private Paying Clients (MBS, Private Health, etc.)

Service Agreement General Form

Sunshine Speech Service Agreement

Client Details

Name

First Name

Last Name

Date of birth

YYYY

Address

Parent and/or Guardian (please complete it client under 18 years)

Please complete if client is under 18 years.

Name

Contact Number

(###)

###

####

Service Provider Details

Sunshine Speech and Allied Health ABN: 91 676 136 351 Phone: 0487 544 125 Email: hello@sunshinespeechalliedhealth.com.au

Service Type

Occupational Therapy

Speech Pathology

Payment Information

We ask all clients to provide credit card details to secure all appointments. All details are securely stored, adhering to industry compliance requirements. Please Note: 1. Payment Authorisation: By providing your credit card you authorise Sunshine Speech and Allied Health to charge your card on the morning of your appointment. 2. Cancellation Policy: Please refer to the 'Cancellation' section of this agreement for our terms. 3. Privacy Assurance: Your credit card information is securely processed and stored in compliance with industry standards to ensure your personal and financial information is protected.

Cardholder Name

Card Number

Expiry Date

CCV

Agreement Details

This agreement is made between Sunshine Speech and Allied Health and:

Client Name

First Name

Last Name

Parent/Guardian (if required)

Service Description

Service Type: Speech Pathology and/or Occupational Therapy Support Services Include: - Assessment (formal and informal) and personalised goal-setting. - Establishment of therapeutic plan and therapy goals - Intervention, including ongoing review of progress - Collaboration with multidisciplinary team and/or relevant health professionals - Reporting - Intervention planning, development, and utilisation of tailored home programs/activities.

Direct and Indirect Services

Our fees include direct and indirect services which include (but not limited to): - Assessment and intervention sessions - Multidisciplinary team meetings - Clinical note keeping - Goal and therapy planning - Reporting, phone calls, letters and/or other communication with involved care team

Service Delivery

Individual

Fee Schedule

At Sunshine Speech and Allied Health we aim to provide high quality and individualised services to support each client develop and achieve their goals. Our dedicated team of experienced allied health professionals are committed to providing the highest level of service to each client and their families. We are a privately owned and operated service. This means we are a fee for service clinic. We do however have various funding streams and Medicare rebates available to assist our clients. Please refer to our Fee Schedule for our current fees.

Agreement Expectations

Start Date of Agreement

YYYY

Text

Who is making this agreement?

Name

First Name

Last Name

Line

What is expected of the client and/or parent/guardians?

Line

What is expected of Sunshine Speech and Allied Health?

Sunshine Speech and Allied Health agree to: - Treat all clients and interested parties with courtesy and respect - Acknowledge all rights and choices - Work with each client and interested parties to provide supports that fit with your individual needs and goals - Discuss with you and/or parent/guardian how best to provide supports and review services when asked - Listen to all feedback and resolve problems quickly - Keep clear records, only use personal information in accordance with current legislation - Provide invoices that clearly show the services being charged and provide receipts upon request which include all relevant information for rebate claiming

Changes and/or Termination of Agreement

If at any time throughout the agreement period changes to service or support are required all parties agree to: - discuss, review and update this agreement to reflect - that all changes be in writing, agreed to and signed and dated by all parties. Should either party with to end this Service Agreement they must provide 14 days written notice. If either party breaches this Service Agreement the required notice period will be waived.

Line

Cancellation Policy

We prepare for each client appointment thoroughly, limiting the number of clients seen each day to ensyure the provision of a quality service. In order to maintain this high level we have a STRICT cancellation policy. We require a minimum 48 hours notice, otherwise a cancellation fee will be charged which is equivalent of 100% of scheduled appointment charge. Repeated failures to attend scheduled appointments may result in discharge from service.

Payment Information

Clients are required to provide valid credit card details to secure their appointment. Payment Processing: Payments will be processed on the morning of the scheduled appointment. Confidentiality: All credit card details will be stored securely and handled in accordance with privacy laws.

Privacy

Sunshine Speech and Allied Health is committed to the confidentiality and privacy of all personal information, with strict policies and procedures in place to ensure all information collected and maintenance processes comply with duty of care obligations and relevant legislation.

Information Collection and Personal Record Keeping

Sunshine Speech and Allied Health are required to collect and record personal information and any other relevant information as a part of providing speech pathology services. The collection of personal information is necessary to provide all participant's with high quality, person-centred support. All client information is gathered as needed and stored securely ensuring privacy is maintained at all times. At any time, the client and/or their parent/guardian is able to access personal information. All personal information gathered by Sunshine Speech and Allied health will remain confidential with the following exceptions: - It is subpoenaed by court, or authorised by law; - Failure to disclose the information would in the reasonable belief of Sunshine Speech and Allied Health place the client or another individual at serious risk to life, health or safety; - the client and/or parent/guardian has provided consent to share with a third part.

Compliments and/or Complaints

Sunshine Speech and Allied Health welcomes all feedback, compliments and complaints. Please contact us at hello@sunshinespeechalliedhealth.com.au. To ensure any issues are addressed immediately, please don't hesitate to reach out to discuss.

Agreement Signature

This parties agree to the terms and conditions of the Service Agreement. The parties agree to accept email confirmation, typed or electronic signatures as binding for any changes.

Client (or nominee signature)

First Name

Last Name

Date

YYYY

Participant Consent Form

Sunshine Speech and Allied Health needs to collect information about you for the primary purpose of providing a quality service to you. To thoroughly assess, diagnose and provide therapy, we need to collect some personal information from you. This information will be used for: - administrative purposes; - billing; - disclosure of information to your care team to facilitate communication and best possible support. All personal information gathered by Sunshine Speech during support provisions will remain confidential except when: - it is subpoenaed by court; - failure to disclose the information would in the reasonable belief place you or another person at risk; - your approval has been obtained.

Consent for Information Collection:

I, (participant or nominee name), understand and consent to Sunshine Speech collecting and recording my personal information as necessary for providing services.

(Participant or nominee name)

First Name

Last Name

Date

YYYY

Get in Touch.

Interested in working together? Fill out some info and we will be in touch shortly. We can’t wait to hear from you!

Alternatively you can call us on 0487544125 or email hello@sunshinespeechalliedhealth.com.au.

Name

First Name

Last Name

Phone

(###)

###

####

What is the main reason for referral?

Speech Pathology

Occupational Therapy

Social Communication Group

How did you hear of us?

Message

New client forms

Form 01.

Form 03.

Get in Touch.

Sunshine Speech & Allied Health