Skip to main content
Telehealth
Book Online
About
Appointments & Telephone Support
Billing
COVID-19
FAQ's
Teaching Health Professional Students
News
Services
General GP & Routine Care
Vaccinations
Mental Health Support
Eating Disorders
Pre-Work Medicals
Dive Medicals
Pre and Post-natal Care
Skin Checks
Our Clinics
General Practice
Occupational Therapy
Physiotherapy
Psychology
Speech Pathology
Exercise Physiology
Interprofessional Clinic
Community Clinics
Dietetics
Chronic Condition Coaching Clinic
Referrals
Speech Pathology Adult Referral Form
Speech Pathology Paediatric Referral Form
JCU Psychology Clinic Referral Form
Occupational Therapy Referral Form
Exercise Physiology Referral Form
Interprofessional Clinic Referral Form
Contact
Home
Referrals
Speech Pathology Paediatric Referral Form
Speech Pathology Paediatric Referral Form
Child's Details
Child Full Name
Date of Birth
Home Address
Parent/Guardian's Details
Parent/Guardian 1
Parent/Guardian 1 Full Name
Occupation
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
Parent/Guardian 2
Parent/Guardian 2 Full Name
Occupation
Home Address (if different from child's)
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
Education
School/Day Care
Grade
Reason for Referral
Please tick the area/s that best describes the reasons for concern for your child
This field is required
Speech sound production errors (e.g. says “tup” instead of “cup”)
Difficulty following directions at home or at school
Difficulty expressing needs or opinions
Limited vocabulary
Difficulty concentrating or attending to school work
Has been diagnosed with Auditory Processing Disorder
Stuttering
Social skills problems that is, difficulty interacting with adults or peers/making friends and/or maintaining friendships
Does not seem to be communicating as well as others of the same age
Difficulties with spelling or reading
Demonstrating frustrated behaviours due to difficulty communicating or understanding
Fine motor skills (e.g. drawing, pencil grip, cutting)
Gross motor skills (e.g. running jumping, skipping)
Self-help skills (e.g. dressing, toileting, brushing teeth)
Sensory differences
(you may select more than one)
What are your main priorities/goals at this time?
What are your child’s main strengths and interests?
Diagnosis
This field is required
Has your child received a medical diagnosis of any disorder, disability or syndrome?
Yes
No
If yes, please specify
If yes, when was the diagnosis received?
Previous Services
This field is required
Is your child receiving services from another allied health provider?
Yes
No
(e.g. occupational therapy, physiotherapy, psychology)
If yes, please specify
This field is required
Has your child accessed any other allied health services in the past?
Yes
No
(e.g. Qld Health, Disability Services, private therapists, Department of Education)
If yes, please specify
This field is required
Has your child had a hearing assessment?
Yes
No
If yes, please specify most recent date
This field is required
Was the hearing within the normal ranges?
Yes
No
If no, please specify
This field is required
Has your child had a vision assessment?
Yes
No
If yes, please specify most recent date
This field is required
Was the vision within the normal ranges?
Yes
No
If no, please specify
Book Online
Telehealth
Facebook
