Client Details (the person requiring services)
Please note, Talkativity is not NDIA registered for children under the age of 7. Please call (03) 5941 9852 or email email@example.com before proceeding with this form.
Services you are enquiring about
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.
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.
IMPORTANTYou 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 firstname.lastname@example.org to your contact list.
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.
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.
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.