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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
Consent to services
Parent/Guardian 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 child receiving speech pathology assessment and intervention services from James Cook University.
I consent to the above named child 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
Parent/Guardian 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
Parent/Guardian 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 JCU Speech and Language Clinic exchanging information related to assessment and intervention for my child with the above and below named agencies.
Consenting Name
Relationship to child
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