Intake Form

Please fill out this form for you or your child to be assessed for suitability for services with Wattle Speech Pathology. Please provide as much information as you can to make the process simpler and quicker for you.

Wattle Speech will assess whether you or your child can be seen by our Speech Pathologists including:

Whether the services required fit within our scope of practice and specialities
Availability of appointments

We recognise the challenge of finding Speech Pathology Services in the Canberra region at the moment so recommend you contact multiple Speech Pathologists to find available services. If we are unable to see you or your client we will provide you with the Canberra Speech Pathologist list.

Name of Client

First Name

Last Name

Name of Parent/Caregiver

(If required)

First Name

Last Name

Age of Client

Phone Number

Willing to utilise telehealth

Yes

Flexible but prefer face to face

Description of issue/concern

Please provide any details of why you may require Speech Pathology services, including how it impacts your daily life

Diagnosis / Medical History

Please provide details of any diagnosis you have received or any medical history that may be relevant to your speech pathology needs (e.g. autism, stroke etc.)