Enquiry Form

Talkativity Enquiry Form
Client Details (the person requiring services)
Date of referral

Day Month Year
Date
Full Name *

First Name Last Name
Date of Birth *

Day Month Year
Gender *
Other
Have you attended Talkativity before?

Yes, for this client Yes, for a sibling/family member No
Name of related client (optional)
Has someone recommended that you contact us?

Yes No
Please tick appropriate box

School/educational facility Specialist Doctor Psychologist Family Doctor Other
Name of referrer
Why did they recommend you contact us?
Briefly describe your concerns

0/150
Are there safety concerns?
e.g. falls, swallowing, urgent equipment requests
Please describe
What are your goals? What would you like to achieve from this service?
Does the client have a diagnosis? *

Yes No
Please list
Is the client under the age of 7?
Is the client an NDIS participant?

Yes No
How is your NDIS funding managed?
Please note, Talkativity is not NDIA registered for children under the age of 7. Please call (03) 5941 9852 or email hello@talkativity.com.au before proceeding with this form.
Have you nominated a Plan Manager?
Who is your nominated Plan Manager: *
Company Name
Payments are due at the time of service. Payments received on the day of service will attract an $8 discount. To ensure you can take advantage of this discount, please complete and return our Credit Card Authorisation form so that we can charge your nominated card directly following your appointments.

Please email me your Credit Card Authorisation form
Services you are enquiring about
Select which appointment type(s) you require *

Speech Pathology Occupational Therapy

Availability *

Location for appointments (choose all appropriate)

Pakenham Clinic Beaconsfield Clinic Home School
If you would like school based visits please specify school name and suburb
Please upload any files that may assist us

Browse Files

Cancel of
Contact Information

All correspondence regarding appointments will go to the contact listed below.

If you are filling this out on behalf of another person requiring services, please consider who needs to receive this correspondence.
Contact name *

First Name Last Name
Relationship to client *
Phone number *
Email *
example@example.com
Is there external deadline that these services are required by?
e.g. funding application deadline, funding ending, NDIS planning meeting
Please describe
We will email clinical correspondence to you rather than post unless you nominate otherwise. If you do not wish correspondence to be sent to you via email please check this box

I do not wish to be sent information via email
We send text messages to clients to notify them of appointment availability.

This is ok This is not ok
We will email clinical correspondence to you rather than post unless you nominate otherwise. If you do not wish correspondence to be sent to you via email please check this box

I am happy to receive information including appointment notifications via email I do not wish to be sent information via email
Please enter your address below *

Street Address

Street Address Line 2

Suburb State

Postcode
Client Declaration:

I confirm that I am the client listed above or their legal guardian and I have the authority to consent to the services listed above.

I understand Talkativity is a private service. Fees apply for services even when a referral is provided. More information is available on our website.
Is there any other information that would be helpful for us to know?
IMPORTANT

You will receive an email from Talkativity confirming that we received your submission.

To avoid this email and any other correspondence from Talkativity going to your junk folder, please add hello@talkativity.com.au to your contact list.

Privacy & Consent
Talkativity needs to collect information about you for the primary purpose of providing a quality service to you. In order to thoroughly assess, diagnose and provide therapy, we need to collect some personal information from you. This information will also be used for:
a. The administrative purpose of running the practice;
b. Billing either directly or through an insurer or compensation agency;
c. Use within the practice if passing your case to another speech pathologist within the practice for ongoing management;
d. Disclosure of information to your doctors, other health professionals or to teachers to facilitate communication and best possible care for you; &
e. In the case of insurance, funding or compensation claim it may be necessary to disclose and/or collect information that affects your formal education or return to work where applicable.

Talkativity has a Privacy Policy that is provided to you at your initial consultation, available on our website and Facebook page and is on display in the clinic room. A printed or emailed copy is available on request from reception. This policy provides guidelines on the collection, use, disclosure and security of your information.

To ensure the process of quality treatment provision, information about your assessment results and progress may be given to relevant other service providers who are involved in your management. These may include your doctor, teachers, specialists, insurers, solicitors, employers or others, but only where it is considered to be of benefit to your progress. We will always ensure we have your permission to share this information prior to doing so.
I want to see a copy of the Privacy Information Statement

Yes Not now
Declaration

By signing below I agree that:

I have read the above information and understand the reasons for collecting the information and the ways in which my information may be used.
I understand that it is my choice as to what information I provide and that withholding or falsifying information may act against the best interests of my assessment and therapy progress.
I am aware that I can access my personal and treatment information on request and if necessary, correct information that I believe to be inaccurate.
I understand that if, in exceptional circumstances, access to my information is denied for legitimate purposes, that the reasons for this and possible remedies will be made available to me.
I understand that the practice must obtain additional consent if the information collected is to be used in any ways other than that outlined above.
Name *

First Name Last Name
Signature *

Clear
Should be Empty:

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Mid-day
Early afternoon
After school

Talkativity Enquiry Form

Privacy & Consent