Client Registration Client detailsName* First Last Date of birth* DD slash MM slash YYYY Contact email* Address* Street Address Suburb State Postcode Parent/Guardian 1 detailsParent/Guardian 1 name First Last Relationship to clientPhone numberEmail address Parent/Guardian 2 detailsParent/Guardian 2 name First Last Relationship to clientPhone numberEmail address Siblings (name, gender, age)School details (if applicable)SchoolTeacherYearSpeech pathology historyHas the client seen a Speech Pathologist in the last 12 months? Yes No Name of previous Speech PathologistDoes the client have any relevant formal diagnoses? Yes No Details of the diagnoses.Has the client seen any other therapist(s) in the last 12 months? Yes No Name of other therapist(s)Has the client had a hearing assessment in the last 12 months? Yes No What were the results of this assessment?Are there any family members with a history of communication difficulties? Yes No Please briefly describe these.What are the main concerns/reasons for seeing a speech pathologist?Pregnancy and birth history :- How long was the pregnancy? - Was there anything unusual about the pregnancy or birth (please describe)Developmental history:Were there any concerns around early developmental milestones such as crawling, walking, babbling and talking, toilet training, etc.?How did you hear about us?Upload your documents Drop files here or Select files Max. file size: 64 MB. Consent to share informationI give Unity Speech Pathology consent to contact other healthcare and educational providers involved in my/my child’s care and share information pertaining to the intervention program, goals and progress.* I agreeName First Last Date DD slash MM slash YYYY Signature* I acknowledge that my electronic signature is the binding equivalent to my hand written signature.NameThis field is for validation purposes and should be left unchanged.
