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Waitlist and Referral Form

By completing the following form, you will be placed on our waitlist or be referred to the next available clinician. Please note we are based in the Inner Eastern / South-Eastern suburbs of Melbourne. If you are located outside of this area, you may have a longer wait time.

If you have any issues with filling this form, please contact us via [email protected] and we will get back to you as soon as possible.

Client Name

Client Date of Birth

Client Address (or Suburb)

Guardian Name (e.g. parent)

Referrer Name & Relation to Client (if not parent)

Contact Phone Number

Contact Email

Name of School / Kinder / Day Service (if applicable)

Diagnosis & Main Concerns

Specific Services Required (select all that apply)

Speech/language assessment (with report)

Swallowing assessments (i.e. dysphagia management plans)

Ongoing speech/language therapy

Speech pathology consultations (i.e. communicative partner training; ad hoc visits; care team meetings)

Therapy assistant

Mode of Service (select all that apply)

In-person: home visits (daytime)

In-person: home visits (after school)

In-person: school or kinder visits

In-person: day-service or community visits

Telehealth

Preferred Days and Times

Funding Options

National Disability Insurance Scheme (NDIS)

Transport Accident Commission (TAC)

Medicare-Enhanced Primary Care (EPC)

Other / Private

Have you previously seen a speech pathologist?

Yes

We are currently fully booked for ongoing therapy sessions for 2026. By completing this form, we may be able to support in the following options: (1) assessment and report only (i.e. for plan reviews), (2) waitlist for 2026, or (3) inform you of other services who may be in your area.

Please note that weekends and after-school timeslots are popular and will generally have a longer wait time. Once a suitable timeslot and clinician become available, we will contact you to confirm your availability and set up an initial screening call.