SPEECH PATHOLOGY CASE HISTORY QUESTIONNAIRE

Personal Details

Surname *

Given Names *

Date of birth: *

Gender

MaleFemaleOther

Occupation

Mobile Phone

E-mail Address

Address *

Street address

Suburb

State

Postcode

Name of Emergency Contact

Emergency Contact Phone Number

Relationship

Medicare

Medicare Number *

Reference Number on the Card (e.g. 1, 2) *

Full Name as on Medicare Card *

Medicare Expiry Date *

Referral

Were you referred for speech pathology?

YesNo Self-referral

If yes, who referred you for speech therapy?

What were the concerns that resulted in a speech pathology session being booked?

Family History

Who lives in the home?

What languages are spoken at home? Please list

What is your dominant language?

Do any family members have a history associated with

SpeechLanguage orHearing

If yes, please explain (speech, hearing, language)

Are there any culture, values, or beliefs you have we should be aware of?

YesNo

If yes, please explain

Medical History

Have you been diagnosed with any conditions?

YesNoUnsure

If yes, please list diagnoses and date of diagnosis (is possible)

Have you had any major medical issues or needed to be on any medications for long periods of time?

YesNo

If yes, please explain and list the medications

Do you feel healthy at present? If no, please comment

Medical and Allied Health Professionals

Please list the professionals inolved in your care ( please provide their names and practice details i.e. company names)

G.P./ Family Doctor

Paediatrician

Speech Pathologist

Occupational Therapist

Physiotherapist

Ear, Nose and Throat (ENT) Specialist

Please list other professionals not mentioned above who are involved with your care

General

Describe your current speech, language, or communication difficulties

Have you previously seen any other speech pathologists? If yes, when and for how long?

If yes, what were their conclusions or suggestions?

When was the problem first noticed?

What do you think may have caused the problem?

Has the problem changed since it was first noticed? If yes, please explain

Are there situations where the problem is better or worse?

Have you ever tried to improve your current difficulty? What were the results?

How do you feel your communication problem has affected your social life, career, education, etc?

Please provide any additional information that might be helpful in the assessment or treatment process

What are your goals for therapy? *

Session Preferences

How often would you like to have speech therapy sessions? *

Do you have a preferred time of day for speech therapy sessions? Please note them here

What is your preferred location for speech therapy sessions? *

Clinic-based (sessions conducted on-site at SASHC)Home

If external location selected, please provide the address

Please note that all external speech therapy sessions will incur a travel fee. In the interest of providing the best possible service to our patients, we limit travel to 10km from our clinic. We will provide you with a quote for travel and speech pathology sessions prior to commencing therapy sessions.

Payment Options

If Other, please list funding option

If NDIS plan-managed, please provide further details

Plan Manager Name

Plan Manager Phone Number

Plan Manager E-Mail Address

Collection Statement

Allied Health Services

SASHC is required to collect and record personal information about you and your child in order to provide quality allied health services. This may include assessing, diagnosing and providing therapy. This information is relevant to your situation, such as your name, contact information, medical history and other relevant information as part of providing services to you. This collection of personal information will be a necessary part of the assessment and/or treatment that is conducted.

Purpose of Collecting and Holding Information

All personal information gathered as part of your assessment and treatment, is kept securely. In the interest of your privacy this information is only used by your therapist/s and authorised Speak Hear staff . Your personal information is retained for record keeping purposes and enables your child’s therapist to provide a relevant and informed service to you. A more detailed description is provided in the Speak Hear “Privacy Policy”. This policy is available to you on request.

Access to client information

At any stage you are entitled to access your child’s personal information kept on file, subject to exceptions in the relevant legislation. SASHC will discuss with you your different possible forms of access.

Disclosure of personal information

All personal information gathered by SASHC during the provision of allied health services will remain confidential, however, please note that by signing and acknowledging this document, you accept that information will be shared with other allied health professionals involved in your care.

Please notify us if you do not wish us to disclose this information or if a court order is in place.

Audio/Video Recording

As a therapeutic clinic, we often make recordings of sessions and assessments for both analysis and planning. We may also utilise some of these recordings for teaching purposes. Your recordings will be kept secure and will not be shown to individuals not associated with our practice/clinic.

On behalf of SASHC, we undertake that, in respect of any audio/video recordings made, every effort will be made to ensure professional confidentiality and that any use of these audio/video recordings, or descriptions of audio/video recordings will be for professional use only and in the interest of improving professional standards through research and training programmes. Every effort will be made to ensure the anonymity of all those involved in the session.

Do you agree with the audio/visual statement above? *

YesNo

Cancellations

Self-funded appointments

The Provider will send out reminders for all scheduled appointment, however, no shows and appointments cancelled within the short notice period (defined by the Provider as notice of less than 48 hours from the scheduled appointment slot) from the scheduled time will incur a fee of 100% of the agreed fee.

NDIS appointments

We understand that at times appointments will need to be cancelled due to illness and unavoidable circumstances. However, in order to provide an affordable and viable service, SASHC has adopted the following cancellation policy in line with NDIS policy.

We will send out reminders for all scheduled appointments, however, no shows and appointments cancelled within the short notice period (defined by the NDIS as less than 2 clear business days) from the scheduled time will incur a fee of 100% of the agreed fee associated with the activity from the Participant's plan.

Late attendance

We make every effort to send out appointment reminders, and we ask that you respect our clinicians time. Arriving late not only impacts your appointment but also those of other patients scheduled throughout the day. Consequently, we are unable to complete full assessments for late arrivals. Therefore, patients who arrive 10 minutes or more past their scheduled appointment time will not be seen and a full appointment fee will be charged.

Fees and Rebates

Fees Payable

If you are a Medicare client, you are required to pay the fee in full on the day of the appointment. Your rebate will be processed through MEDICARE and will be deposited into your nominated bank account within 24 hours of service if you are registered with MEDICARE for rebates.
All private health rebates will be made through HICAPS on the day of the appointment.
If you are an NDIS participant and the NDIA does not pay any account associated with the service provided you will be legally responsible to pay SASHC for the unpaid accounts.
Reports of any type will not be released without prior payment.

Consent

I (please print name) *

have read, understood and agree to the above conditions, and as the authorised person, agree to the provision of services by SASHC.

Signature *

Draw signature|Type signatureClear

Date *