Screener Intake Questionnaire

About Speech Pathology Screenings

Speech Pathology screenings are crucial to early identification of a variety of communication difficulties. They can help address any concerns you may have and give you a clearer picture as to whether intervention may be required. Research continues to support the benefits of early intervention for children with speech, language and learning difficulties.

The screenings are individual and take approximately 20- 25 minutes. Within these screenings the areas of expressive language, understanding of language, social language, speech sounds, stuttering and pre-literacy (when applicable) will be looked at. It is important to be aware that screening results are not in any way a definitive diagnosis, and that if areas of concern are identified; further thorough and standardised assessment will be required.

Within 3-4 weeks of the screenings taking place you will be given a summary report outlining your child’s strengths and weaknesses. This report will also include any relevant recommendations (e.g. the need for further assessment or a hearing assessment). We will also liaise with the preschool Educators in how to best support your child.

Welcome! A quick note:

Data collected in this questionnaire can only be accessed, viewed and saved in your child's file by administrative and clinical staff employed at Hills District Speech Therapy using a secure login system. By completing this questionnaire you agree to the collection, viewing and storage of your information into our health practice software 'Cliniko' for screening and future assessment and therapy purposes if indicated.

Thank you for participating in Speech Pathology Screenings at your child’s preschool/school. For more information about our screenings, please refer to our website.
Is your child booked onto their screener within the next 2 days?
- Yes
- No
Unfortunately you have missed the cut off day for booking your child in for a screener at their childcare centre/preschool. Online forms and payment must be received at least 2 business days before the scheduled appointment.

Please contact us directly on 9054 1996 or bookings@hdspeechtherapy.com.au for further information.
Date your child is booked in for their screener*
DD slash MM slash YYYY
Client's first name*
Child's surname*
Child's date of birth*
DD slash MM slash YYYY
Child's Age*
Name of pre-school/childcare centre/school your child attends:*
Home address*
Suburb
Postcode*
Parent/Guardian’s details
Parent/Guardian’s full name*
Parent/Guardian’s contact number*
Parent/Guardian’s email:*
Are there any custody arrangements in place that Hills District Speech Therapy must be made aware of?
- Yes
- No
Please provide more information*

Parental consent
I [enter your full name below] give consent for Hills District Speech Therapists to:
Please tick all to confirm acceptance*
- Screen my child at his/her preschool
- Liaise with preschool staff about my child
- Provide information to the staff about your child’s results (via verbal and written report)
Please sign using your mouse or finger on touch devices.*

Please select your method of payment*
- Direct Deposit Transfer to HDST
- Card Authorisation
Please transfer $55 to the below account in order to secure your booking.
Account Name: HDSPEECH
BSB: 083 004
Account Number: 29 371 5252
Reference: Your child's full name/invoice
You will receive a card authorisation form via email. Please return this form to bookings@hdspeechtherapy.com.au in order to secure your booking. Your $55 payment will be taken securely using Stripe.
Check to agree:*
- To secure your child's screening appointment, you agree to pay at least 2 BUSINESS DAYS prior to the screening. Your child will not be screened on their allocated day unless payment has been made.
You will receive a closed invoice upon us receiving payment. This can be claimed through your private health insurance.

Should you have any concerns regarding payment or your child's screening, please contact us on 90541996 or bookings@hdspeechtherapy.com.au.

Step 1 of 6 - About

Parent/Guardian’s details

Child's History

Concerns

Parental consent