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Referrals
Speech Pathology Adult Referral Form
Speech Pathology Adult Referral Form
Client's Details
Full Name
Date of Birth
Home Address
Email
Home phone
This field is required
Can we leave a message at this number?
Yes
No
Mobile phone
This field is required
Can we leave a message at this number?
Yes
No
Are you listed on a health care or pension card?
This field is required
Yes, health care card
Yes, pension card
No, neither
Occupation
Highest level of education
Primary Medical Practitioner
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Practitioner Type
GP
Specialist
Medical Practitioner Address
Medical Practitioner Phone
Medical Practitioner Fax
This field is required
Is an Enduring Power of Attorney (EPOA) for health currently responsible for making health decisions on your behalf?
Yes
No
If yes, please complete the following with the EPOA holder’s details.
Full Name
Relationship to client
Home Address (if different to the clients)
Email
Home phone
This field is required
Can we leave a message at this number?
Yes
No
Mobile phone
This field is required
Can we leave a message at this number?
Yes
No
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
This field is required
Have you received a medical diagnosis?
Yes
No
(e.g. stroke, TBI, dementia, Parkinson’s etc.)
If yes, please specify
If yes, when was the diagnosis received?
Previous Services
This field is required
Are you receiving services from another allied health provider?
Yes
No
(e.g. occupational therapy, physiotherapy, psychology)
If yes, please specify
This field is required
Have you accessed any other allied health services in the past?
Yes
No
(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.
*
This field is required
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
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.
This field is required
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):
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