Speech Pathology Adult Referral Form

Client's Details

Full Name

Date of Birth

Home Address

Home phone

Can we leave a message at this number?

Mobile phone

Can we leave a message at this number?

Are you listed on a health care or pension card?

Yes, health care card

Yes, pension card

No, neither

Occupation

Highest level of education

Primary Medical Practitioner

Practitioner Type

Medical Practitioner Address

Medical Practitioner Phone

Medical Practitioner Fax

Is an Enduring Power of Attorney (EPOA) for health currently responsible for making health decisions on your behalf?

If yes, please complete the following with the EPOA holder’s details.

Full Name

Relationship to client

Home Address (if different to the clients)

Home phone

Can we leave a message at this number?

Mobile phone

Can we leave a message at this number?

Reason for Referral:

Please describe the difficulties you are having that have lead you to access this clinic.

What are your main priorities/goals at this time?

Diagnosis

Have you received a medical diagnosis?

(e.g. stroke, TBI, dementia, Parkinson’s etc.)

If yes, please specify

If yes, when was the diagnosis received?

Previous Services

Are you receiving services from another allied health provider?

(e.g. occupational therapy, physiotherapy, psychology)

If yes, please specify

Have you accessed any other allied health services in the past?

(e.g. Qld Health, Disability Services, private therapists, etc)

If yes, please specify

Consent to services

Client or EPOA for health to tick applicable boxes to indicate consent. If you do not wish to consent, please leave boxes blank. Please be aware that you are able to change your consents at any time by contacting the clinic. *

I consent to the above named client receiving speech pathology assessment and intervention services from James Cook University

I consent to the above named client receiving services provided by JCU speech pathology students under the direct supervision of fully qualified and registered speech pathologists.

I understand that if I fail to attend 3 appointments with without notifying the clinic beforehand, no further appointments will be offered.

Consent to DVD recordings

I consent to clinic sessions being recorded for individual student viewing and learning.

I consent to the use of clinic session recordings being used within the Discipline of Speech Pathology for educational and demonstration purposes in lectures, tutorials and practical sessions for speech pathology students. I understand that identifying information related to these recordings will be kept confidential.

I consent to Speech Pathology students copying segments of DVD recordings for inclusion in their student portfolio as evidence of professional skills.

I consent to being involved in promotion of the JCU Speech & Language Clinic including photographs, quotes and interviews with the press.

Consent to exchange of information

I consent to the JCU Speech and Language Clinic exchanging information related to assessment and intervention for the above named client with the above and below named agencies (provide details as applicable)

Full Name

Relationship (Self/EPOA):