Medicare Speech Pathology Intake Form

Gender

Male Female Other

Do you have a pension card?

Yes No

Do you have private health insurance?

Yes No

If you have private health insurance, please provide the name as shown on the card

If you have private health insurance, what number on the card are you?

If you have private health insurance, what is the name of the company you are with?

If you have private health insurance, what is the number on the card?

Doctor/Referrers name?

Medicare number and expiry date

What number are you on the Medicare card

Emergency Contact Number

Communication and Social Interaction

Does the client Play Well with Other Children/individuals?

Yes No Half/half

Which of the Following Apply?

About How Much of What Your Child/client Says Can You Understand?

All/almost all Most Half Quarter or less

What Is the Main Goal You Wish to Accomplish with Speech/Language Therapy?

By signing this form, I hereby give my consent for:

The participant to receive Speech Pathology services from AngelCare and agree to pay all associated fees, including a Medicare Gap, for these services in accordance with AngelCare policies
AngelCare to contact and share information and reports with educational staff, medical practitioners, specialists, and health professionals involved in the participants care
If the client is a child, I understand and agree that physical guidance contact between my child and their treating Speech Pathologist as necessary. I acknowledge that all care is taken whilst working with my child however physical contact may be required for guidance during therapy sessions, and that such contact will only be used to ensure the best outcome for the individual. I understand physical guidance may involve hand-over-hand prompting, guiding the individual into a seated position, etc.

In addition, by signing below, I confirm that I understand and agree:

To pay all fees and charges for the individual's Speech Pathology services on or before the date of the session
If applicable, I am to be present for at least the first 5 minutes, and last 10 minutes, of my child’s session unless otherwise advised/agreed
If applicable, I am responsible for supervising my child/ren whilst at AngelCare

The above must be at least 18 years of age, otherwise consent from a custodial parent is required to treat a minor. Your signature confirms that you have read and give consent to AngelCare Clinic Policy.

Confirmation

I confirm that I want to receive content from this company using any contact information I provide.

Medicare Speech Pathology Intake Form

Medicare Speech Pathology Intake Form

Angel Care

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