Speech Pathology Referral Form

Once you have completed the form please email it back to admin@steps2lifecare or if you have any questions or
need support filling this form out, please call us on 02 9638 3362 .

Please allow for 3 business days for your referral
to be processed. 

 

Important information regarding your referral, please read

Please note that we are not and emergency service. If the client is at high or acute risk of suicide, please contact emergency services on 000 or attend your nearest hospital emergency department.

We make every attempt to see clients referred for services at Steps 2 Life. If it is determined that we are not able to support the client’s needs, we will advise you of this as soon as possible and will attempt to refer you to a more suitable service.

When completing the referral, could you please provide any relevant assessments, reports, and/or additional information you may have regarding the client.

Form Comming Soon

    REFERRER DETAILS : Steps 2 Life will be corresponding with you using the below details. Please ensure that all details are fully completed.

    Parent / Guardian/ Next of Kin Details

    Are you the legal guardian of the client ?

    CLIENT DETAILS

    Gender Identity:

    Does the client have a Referral from a GP for Speech Therapy services?

    If yes, please email your referral to admin@steps2lifecare.com.au prior to your appointment

    Does the client have a NDIS plan with funding for Speech Therapy services?

    FAMILY BACKGROUND

    Who lives at home with the child? (Please list all people in the household below)

    Has anyone in your family had difficulty with any of the following: (please include age of onset and duration)
    Speech/Language

    Coordination

    Learning

    Developmental Delay

    Mental Health

    Behaviour

    LANGUAGE AND CULTURAL BACKGROUND

    DEVELOPMENTAL HISTORY

    SKILL : AGE ACHIEVED IN MONTHS (APPROXIMATE) Please enter the approximate age when your child achieved the following skills. If you are unsure, please enter ‘Not Sure’. If a child has not yet achieved the skill, please enter ‘Not Yet Achieved’.

    MEDICAL HISTORY

    Does your child have a diagnosis. If yes, please provide details (e.g. age of child at diagnosis, early intervention if any etc):

    Are you concerned about your child’s vision?