PLEASE NOTE:

Due to high demand, The Speech Guy & Co. currently does not have immediate capacity for new clients. By completing this referral form, you (or the referred client) will be placed on a wait-list. The current estimated wait time is approximately 2-3 months.

Step 1 of 8

Contact Information

Please provide the client’s contact details.

Title *

Name *

First

Last

Date of Birth *

Residential Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Postal Address

Same as Residential Address

Phone Number *

Email *

Terms and Conditions

Privacy & 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 outlined on the following webpage: https://www.thespeechguy.com.au/fees-and-funding/

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, or at the time of appointment (for NDIS self-managed clients). 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? *

Referral Form

Contact Information

Funding Methods

Medicare

Private Health Fund

NDIS Funding Details

NDIS Plan Manager

NDIS Support Coordinator

Home Care Package

Self Funded

Next of Kin

Medical History and Disabilities

Language Background

Additional Referral Information