Referral Form – Santoro

GENERAL INFORMATION

Full name (child's name if under 18)

First Last

Preferred name

Date of birth

Sex

Gender identity

Ethnicity

Referral ID

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone (parent/guardian contact number if child under 18)

Phone

Add New Phone Number

Email (parent/guardian email if child under 18)

Guardian/Nominee

First Last

Guardian/Nominee Phone number

Guardian/Nominee Email

Preferred Contact Method

Phone Calls

Emails

Text Messgaes

How did you hear about us?

MEDICAL INFORMATION

Diagnosis

Medications

Medication

Frequency

Add a Medication

GOALS

By completing this intake form, you agree to participate in an initial Speech Pathology Assessment. This assessment will help identify your needs and establish therapy goals. After the assessment, a service agreement will be provided, outlining the therapy plan based on the agreed-upon goals. You will have the opportunity to review and consent to the terms of the service agreement before continuing with therapy. This will be charged out as per the NDIS Price Guide rates.

Funding Stream Type (NDIS, Private, Medicare, DVA etc)

Fund management

Email address where invoices are to be sent

NDIS number (please write N/A if you are not NDIS funded)

Plan start date

Plan end date

Please upload a copy of your NDIS Plan here

Max. file size: 20 MB.

Location of Services

Clinic

Do you have a Support Coordinator?

Support Coordinator Name

Support Coordinator Contact email

Support Coordinator Contact phone number

For MEDICARE Rebate: (Details of the person who will be making claim to Medicare)

Card number Reference number

Claimant's Date of Birth (For Medicare Clients)

FINANCIAL INFORMATION

Services Required

Speech Therapy (Face to Face)

Telehealth Speech Therapy

Sensory Assessment

A.D.O.S Assessment

Community age care

Skill Building Training for Adults

AAC Assessment and Training

Above are our Specialised Therapeutic Approaches. Please select which service you are requiring. May choose more then one.

Other - details

Location of services

Date and time of attendance at Location of services

Reason for referral (i.e. Goals and desired outcome)

POLICY INFORMATION

Statement title

Cancellations must be made with a minimum of two (2) clear business days' notice to avoid charges. Short-notice cancellations (less than two business days) or no-shows may incur a fee of up to 100% of the scheduled service cost, as per NDIS pricing guidelines. For services arranged through third-party referrals, any cancellation after referral acceptance will incur a fee equal to the total cost of the initial appointment.

I have read the above cancellation policy and understand that Short Notice cancellations will be charged as per the NDIS Guidelines.

Yes