Thank you for requesting an appointment with Next Challenge
Please complete the following questions so that we can provide you with the best possible service.
Child's First Name
Date of Birth
Your First Name
Best Phone Contact
Best Email Contact
School / Daycare
How did you hear about Next Challenge?
DSC Provider List
Sibling has been to Next Challenge
Do you need an interpreter for appointments?
If yes, what language does the interpreter need to speak?
Emergency Contact Details
In case of emergency, we require details for an alternate contact person for your child.
Emergency Contact Name
Emergency Contact Number
How can we help you?
What type of therapy are you looking for?
Literacy Check Assessment (Speech Pathology)
Feeding and/or mealtime concerns (Speech Pathology)
Dietetics / Nutrition
We are not sure at this stage and would like your help with this
How will you be accessing our Services?
Self funded - we will pay in full and/or arrange private health insurance reimbursement
We have a Medicare care plan in place with our GP. (Please email us a copy of the plan)
We are eligible for the Helping Children with Autism program. (Please email us a copy of your registration letter)
We have a NDIS plan or are developing one. (Please email us a copy of your plan)
We self-manage NDIS funds.
We are not sure as yet and would like to talk to someone more about our options.
Please provide a brief outline of your current concerns for your child
When are you available for appointments?
After school only
School hours only
We are flexible
Do you have a preference for where we see you?
School visit/ Daycare visit
Main Street Osborne Park therapy rooms
Mandurah Therapy Rooms
School Based Therapy (St Helena's, Queen of Apostle, Regent College only)
Are you interested in online sessions?
Yes - I'd like more information about this option
Yes - we would like to see if online sessions would suit us
Yes - we wish to book an online Lisp Check Assessment
Not at the moment
Is there any other information that you think we should know about?
Can we add you to our mailing list for occasional newsletters or update mail outs? (You can unsubscribe at any time)
No thank you
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