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Hills District Speech TherapyHills District Speech Therapy
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  • HOME
  • ABOUT US
    • OUR MISSION
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    • WORK AT HDST
  • SPEECH THERAPY
    • THE THERAPY PROCESS
    • SCREENINGS
    • ASSESSMENT
    • WHO WE SEE
      • INFANTS & TODDDLERS
      • PRESCHOOL
      • NEURODIVERGENT
      • 18+
    • HOW WE HELP
      • SPEECH
      • LANGUAGE
      • LITERACY
      • STUTTERING
      • AAC
      • FEEDING
      • OROFACIAL MYOLOGY
    • PAIRED PEER THERAPY
    • ONLINE THERAPY SERVICES
    • ALLIED HEALTH ASSISTANTS
    • SCHOOLS AND PRESCHOOLS
    • WORKSHOPS AND EDUCATION
      • VOICE PROTECTION & PROJECTION
      • HANEN PARENT WORKSHOPS
        • IT TAKES TWO TO TALK
        • MORE THAN WORDS
    • WAITING FOR SPEECH THERAPY
  • OCCUPATIONAL THERAPY
    • ASSESSMENT
    • INDIVIDUAL THERAPY
    • PAIRED PEER THERAPY
    • ONLINE THERAPY SERVICES
    • WAITING FOR OT
    • OT SHOP
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      • LEGO® GROUP
      • SOCIAL GAMERS
      • SCHOOL READINESS
      • ORAL NARRATIVE
      • WRITTEN EXPRESSION
      • LITERACY FOUNDATIONS
      • EARLY LANGUAGE GROUP
      • PEERS
      • GET SET GROUP
    • GROUP OCCUPATIONAL THERAPY
      • SCHOOL READINESS
      • TREEHOUSE CLUB
      • REGULATION WARRIORS
      • MINI PICASSO
  • ADULT SPEECH THERAPY
    • THE THERAPY PROCESS
    • ASSESSMENT
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      • LANGUAGE DIFFICULTIES
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      • PARKINSONS DISEASE
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Questionnaire - Hills District Speech Therapy

"*" indicates required fields

Step 1 of 9 - About You

11%

HOW HILLS DISTRICT SPEECH THERAPY HANDLES YOUR PERSONAL INFORMATION WHEN YOU VISIT OUR WEBSITE

This section of our Privacy Policy explains how we handle your personal information which is collected from our website: www.hdspeechtherapy.com.au.

This Privacy Policy applies to your use of our website and the use of any of the facilities on our website.

3.1 Collection

When you use our website, we do not attempt to identify you as an individual user and we will not collect personal information about you unless you specifically provide this to us. Sometimes, we may collect your personal information if you choose to provide this to us via an online form or by email, for example, if you:

  • submit a general enquiry via our contacts page;
  • register to receive eNewsletters; or
  • send a written complaint or enquiry to our Practice Managers.

When you use our website, our Internet Service Provider (ISP) may record and log for statistical purposes the following information about your visit:

  • your computer address;
  • your top level name (for example, .com.,gov., .org, .au etc.);
  • the date and time of your visit;
  • the pages and documents you access from our website during your visit; and
  • the web browser you are using.

Our web-site management agent may use statistical data collected by our ISP to evaluate the effectiveness of our website.

3.2 Cookies

A "cookie" is a device that allows our server to identify and interact more effectively with your computer. Cookies do not identify individual users, but they do identify your ISP and your browser type.

This website uses temporary cookies. This means that upon closing your browser, the temporary cookie assigned to you will be destroyed and no personal information is maintained which will identify you at a later date.

Personal information such as your email address is not collected unless you provide it to us. We do not disclose domain names or aggregate information to third parties other than agents who assist us with this website (WP Perk: Wordpress Support) and who are under obligations of confidentiality. You may be able to configure your browser to accept or reject all cookies and to notify you when a cookie is used. We suggest that you refer to your browser instructions or help screens to learn more about these functions. However, please note that if you configure your browser so as not to receive any cookies, a certain level of functionality of the (name of the practice) website and other websites may be lost.

3.3 Links to third party websites

We may create links to third party websites. We are not responsible for the content or privacy practices employed by websites that are linked from our website.

3.4 Use and disclosure

We will use any personal information collected via our website in accordance with our privacy policy

Consent*

Welcome to Hills District Speech Therapy

Please fill in this online questionnaire as best you can and bring any relevant reports with you to your next appointment . Please Note: All information you provide us is confidential and will only be shared given your consent.

Type of Client
Please select from the following options. The client is:*
*Note: offsite visits are not guaranteed and are dependent on clinician availability. For home visits, these are only conducted Mon-Fri between 9am and 2pm

Personal Information

DD slash MM slash YYYY
DD slash MM slash YYYY

Contact Details


Contact Person 1


Contact Person 2

Main Parent/Carer for correspondence
Are there any custody arrangements in place that Hills District Speech Therapy must be made aware of?
Please inform HDST immediately of any changes in the custody arrangements during your therapy block.
Are you a member of a Private Health Fund?
Will you be requiring home visits from Hills District Speech Therapy?
Are there any biological hazards (e.g. bodily fluids, viruses, infectious diseases…) our clinicians should be made aware of when visiting you?
Are there any pets at the site?
Are there any limitations (e.g. lift, security, clutter, noise…) to accessing the site?
Are there any family/cultural preferences you would like us to follow (e.g. removing shoes at entry)?
Are there any behaviours (e.g. aggression, challenging behaviours) from the client and/or other family members that may create risk for our clinicians?
Is there any manual handling required from the clinician on site?
Is the clinician required to operate any electrical equipment on site?

Reason for Referral

How would you rate this problem?
Has child been seen by another health professional

Has the client been seen by a Speech Pathologist before?
Does your child attend preschool/childcare?
Is your child in a support class?
Has your child been seen by a school counsellor?
Does your child struggle with completing homework tasks?
Is your child receiving additional support/classes (e.g. Minilit):
Is your child in a support class?
Has your child been seen by a school counsellor?
Does your child struggle with completing homework tasks?
Does the client attend a day program?
Does the client work?
Does the client attend an educational institution (e.g. TAFE, University)?
Has the client's communication difficulty prevented them from carrying out activities for work and/or pleasure?

Referral Details

If you were not referred, where did you find out about our services?

Medical History

Does the client have a specific medical history or diagnosis
Is the client on any regular medications?
Does the client have any allergies?
Has the client been seen by an Ear, Nose and Throat (ENT) specialist?
Has the client experienced any of the following?

Family Doctor

Does the client wear glasses/hearing aids?
Is there a family history of speech and or language difficulties?

Developmental History

Has the child's hearing been tested?
Has the child's vision been tested?
Were there any concerns or complications during the mother's pregnancy and the child's birth?
Was your child
Were there any difficulties with feeding your child?
Does your child have any ongoing difficulties with swallowing and/or eating?
Can your child eat a variety of textures?
Please select any of the areas your child developed difficulties with:

Your Goals

Medical History

Does your child have a specific medical history or diagnosis (e.g. Autism, ADHD, Allergies to Peanuts)?
Is your child on any regular medicine?
Has your child had any of the following?
Has your child been seen by an ENT (Ear, Nose and Throat Specialist)?
Has your child had their hearing tested?
Does your child wear glasses?
Is there any family history of speech/ language or learning difficulties?

Goals

Terms and Conditions including consent

Please ready carefully. By giving consent, you are giving Hills District Speech Therapists permission to:

Assess and provide intervention to my child/me as appropriate.
Contact other agencies and professionals in order to obtain relevant information to assist with Speech Pathology intervention and assessment.
Provide information to other agencies and professionals (via verbal and written reports).
Audiotape or videotape sessions if required for intervention purposes.
Take audio and video recordings that can be used for clinician teaching, training and education as well as quality improvement within the HDST clinic.
Take photos and videos that may be used on Hills District Speech Therapy’s social media sites (Facebook and Instagram). Photos and videos will be used in a positive and non-offensive manner in line with HDST policy. *Further verbal consent will be obtained at the time and may be removed immediately upon request.

Other conditions

  1. CANCELLATIONS (Monday-Friday): All appointments at Hills District Speech Therapy are made in advance and therefore reserved to meet your specific requirements and preferences. We understand illness and misadventures occur, however cancellations or the rescheduling of appointments need to be made at a minimum, by 3pm the day prior to your appointment via phone (98997853) otherwise a CANCELLATION FEE of $40.00 WILL APPLY ($48.00 for NDIS clients).
  2. CANCELLATIONS (Saturdays):All appointments at Hills District Speech Therapy are made in advance and therefore reserved to meet your specific requirements and preferences. We understand illness and misadventures occur, however due to the nature and demand of Saturday bookings ALL CANCELLATIONS incur a FEE of $48.00. NDIS clients will be charged a fee of $56.00 if less than 2 business days notice is given for Saturday appointments. Note: there is an exception for Saturday appointment regular attenders - 4 cancellations / year for special occasions with 1 week's notice.
  3. PAYMENT: Is to be made at the time of your consultation and can be made by cheque, Eftpos or credit card. Amex is not accepted.
  4. RECEIPTS: Our accounts team email receipts within 1-2 business days, however please let your Clinician know if you require a receipt on the day. Receipts can also be printed or mailed upon request. Please email accounts@hdspeechtherapy.com.au if you require assistance.
  5. REBATES: are available via Private health funds and Medicare. We do not have HICAPS facilities at this time. To access Medicare rebates, a completed CDM/EPC referral form must be provided from the GP. If you would like more information, please speak to your Therapist about it at your consultation.
  6. REPORT: A report will be emailed to you within 3-4 weeks after the completion of the initial assessment, unless specified otherwise by your clinician. If you require the report sooner, please discuss this with your clinician.
Acceptance of other conditions*
Clear Signature
This field is for validation purposes and should be left unchanged.

Policies and Procedures at HDST
© 2022 Hills District Speech Therapy. | Managed by Wolf IQ

  • HOME
  • ABOUT US
    • OUR MISSION
    • OUR SERVICES
    • POLICIES & PROCEDURES
    • OUR TEAM
    • VIEW CLINIC
    • WORK AT HDST
  • SPEECH THERAPY
    • THE THERAPY PROCESS
    • SCREENINGS
    • ASSESSMENT
    • WHO WE SEE
      • INFANTS & TODDDLERS
      • PRESCHOOL
      • NEURODIVERGENT
      • 18+
    • HOW WE HELP
      • SPEECH
      • LANGUAGE
      • LITERACY
      • STUTTERING
      • AAC
      • FEEDING
      • OROFACIAL MYOLOGY
    • PAIRED PEER THERAPY
    • ONLINE THERAPY SERVICES
    • ALLIED HEALTH ASSISTANTS
    • SCHOOLS AND PRESCHOOLS
    • WORKSHOPS AND EDUCATION
      • VOICE PROTECTION & PROJECTION
      • HANEN PARENT WORKSHOPS
        • IT TAKES TWO TO TALK
        • MORE THAN WORDS
    • WAITING FOR SPEECH THERAPY
  • OCCUPATIONAL THERAPY
    • ASSESSMENT
    • INDIVIDUAL THERAPY
    • PAIRED PEER THERAPY
    • ONLINE THERAPY SERVICES
    • WAITING FOR OT
    • OT SHOP
  • MUSIC THERAPY
    • INDIVIDUAL THERAPY
    • GROUP THERAPY
  • GROUP THERAPY
    • ABOUT GROUP THERAPY
    • SCHEDULE
    • GROUP SPEECH THERAPY
      • LEGO® GROUP
      • SOCIAL GAMERS
      • SCHOOL READINESS
      • ORAL NARRATIVE
      • WRITTEN EXPRESSION
      • LITERACY FOUNDATIONS
      • EARLY LANGUAGE GROUP
      • PEERS
      • GET SET GROUP
    • GROUP OCCUPATIONAL THERAPY
      • SCHOOL READINESS
      • TREEHOUSE CLUB
      • REGULATION WARRIORS
      • MINI PICASSO
  • ADULT SPEECH THERAPY
    • THE THERAPY PROCESS
    • ASSESSMENT
    • INDIVIDUAL THERAPY
      • LIFELONG DISABILITIES
      • LANGUAGE DIFFICULTIES
      • SWALLOWING DIFFICULTIES
      • PARKINSONS DISEASE
      • STUTTERING
    • ONLINE THERAPY SERVICES
    • PAIRED PEER THERAPY
    • GROUP THERAPY
    • WORKSHOPS AND EDUCATION
      • STAFF TRAINING
    • COMMUNITY LINKS
  • FUNDING
    • FEES
    • CANCELLATION POLICY
    • NDIS
    • MEDICARE
    • PRIVATE HEALTH
  • FEEDBACK
    • CLIENT FEEDBACK
    • COMPLAINTS
  • NEW CLIENT
    • NEW SPEECH CLIENTS
    • NEW OT CLIENTS
    • NEW MUSIC THERAPY CLIENTS
    • NEW ADULT CLIENTS
    • EXTERNAL REFERRER