Please enable JavaScript in your browser to complete this form. – Step 1 of 8Contact InformationPlease provide the client’s contact details.Title *Please specifyMr.Ms.Miss.Mrs.Mx.OtherTitle (Other)Name *FirstLastDate of Birth *Residential Address *Address Line 1Address Line 2CityState / Province / RegionPostal CodePostal AddressSame as Residential AddressPostal AddressAddress Line 1Address Line 2CityState / Province / RegionPostal CodePhone Number *Email *NextFunding MethodsPlease select the funding methods that you may use for Speech Pathology.Funding Methods *Medicare (e.g. Chronic Disease Management Plan)Private Health FundNDIS (plan or self-managed only)Home Care PackageSelf FundedPreviousNextMedicarePlease advise your Medicare details.Medicare Number *Medicare Reference *Medicare Expiry *Private Health FundPlease advise your Private Health Fund details.Private Health Fund Name *Private Health Fund Member Number *NDIS Funding DetailsPlease advise your NDIS detailsNDIS Number *NDIS Plan Start Date *NDIS Plan End Date *Additional SupportPlan ManagerSupport CoordinatorPlease tick if you have a Plan Manager and/or Support CoordinatorNDIS Plan Manager Please provide the contact details for your NDIS Plan ManagerPlan Manager Name *This may be a person or a company namePlan Manager Email *Plan Manager Phone Number *NDIS Support Coordinator Please provide the contact details for your NDIS Support CoordinatorSupport Coordinator Name *FirstLastSupport Coordinator Email *Support Coordinator Phone Number *Home Care PackagePlease advise your Home Care Package details.Package Provider Name *Package Level *Package LevelLevel 1Level 2Level 3Level 4Case Manager Name *FirstLastCase Manager Email *Case Manager Phone *Self FundedPlease select Next to continuePreviousNextNext of KinPlease advise your Next of Kin details.Next of Kin Name *FirstLastNext of Kin Phone Number *Next of Kin Relationship to Client *PreviousNextMedical History and DisabilitiesPlease list any medical conditions, disabilities or diagnoses that the client has or has had:Medical History *PreviousNextLanguage BackgroundPlease specify the client’s language background informationDoes the client come from a non-English speaking background? *YesNoPlease specify what languages the client speaks *Please specify if an interpreter is required *YesNoPreviousNextAdditional Referral InformationPlease provide any other referral informationReason for Speech Pathology Referral *Additional Comments or InformationPreviousNextTerms and ConditionsPrivacy & Confidentiality The Speech Guy & Co. is committed to protecting the privacy of personal information we collect and hold about individuals. The Speech Guy & Co. complies with the Australian Privacy Principles (APPs) under the Privacy Act 1988 (Cth), other privacy laws that govern how private sector health service providers like The Speech Guy & Co. handle your personal information (including your health information), and Speech Pathology Australia’s Code of Ethics (2010). Your personal information will only be used for the purposes for which it was collected for or as otherwise permitted by law, and we respect your right to determine how your information is used or disclosed. The full Privacy Policy can be found at www.thespeechguy.com.au/privacy-policy. By submitting this form, you are indicating that you agree to the full privacy policy and consent to the collection and handling of your information for the purpose specified in the privacy policy. Fees Fees are detailed below: Speech Pathology assessment, intervention, therapy, education or consultation sessions – $190/hour Travel Fee – $95/visit Reports – The cost of reports can vary from $95 to $950 (at a rate of $190/hour), depending on the type of report and needs of the client. This can be discussed prior to the completion of reports. Clinical communication/liaison (e.g. phone/email correspondence with client or other relevant stakeholders) – $190/hour Preparation of resources (e.g. paper based communication aids, individualised handouts etc.) – If resources are to be created and provided by The Speech Guy & Co., this will be discussed with clients. However, creation, preparation and provision of resources will be charged at a rate of $190/hour. Invoices Invoices will be provided on a weekly basis and will contain a breakdown of services provided for the given week. Payment of fees will be due within one week of the delivery of the invoice. Please be aware that certain funding/rebate schemes may not cover the full cost of the above listed services. Cancellation Policy The Speech Guy & Co. maintains the right to charge a cancellation fee of 90% of the above rate if a booked session is cancelled with less than 48 hours’ notice. If the client was not present at the time of appointment, the travel cost may also be charged at the 90% rate. Responsibilities of The Speech Guy & Co. The Speech Guy & Co agrees to: Protect client’s privacy and confidentiality in accordance with the privacy policy Provide a high quality and evidence based speech pathology service Treat clients with courtesy and respect Consult with clients on decisions regarding the services that they receive from The Speech Guy & Co. Coordinate and liaise with other service providers or stakeholders, where necessary and able Listen to client’s feedback and resolve problems quickly Give clients as much notice as possible if a scheduled appointment needs to be cancelled or changed Provide services in a manner that is consistent with all relevant laws and the Speech Pathology Australia Code of Ethics Issue regular invoices to the client Keep accurate records on the supports provided to the client Responsibilities of clients The client/client’s representative agrees to: Provide The Speech Guy & Co. with accurate information when requested Proactively participate in any sessions and/or homework tasks given The Speech Guy & Co. Treat all staff from The Speech Guy & Co. with courtesy and respect Give a minimum of 48 hours’ notice when cancelling a session, and if this notice is not provided, then accepting the cancellation fee. Ending Services The Speech Guy & Co. maintains the right to cease services, with immediate effect. Reasons may include compromised staff safety, the client is not compliant with these conditions, or the clinician feels that speech pathology would no longer be beneficial. Clients can also cease services at any time.Have you provided accurate information in this form? *YesDo you consent to receiving services from The Speech Guy & Co? *YesDo you agree to the above Terms and Conditions? *YesPreviousSubmit
