NEW CLIENT DETAILS FOR THERAPY WAITLIST

W elcome to Learn and Grow!

Please complete and submit our Client Enquiry form.

Once submitted your child's information will be updated and automatically added to our waitlist.

Our bookings team will then contact you via phone to complete a 'Client Intake Interview' to discuss your child's needs in more detail and to answer any of your questions about our Speech Pathology and Music Therapy services.

T hank you for your enquiry, and we look forward to meeting you soon.

CHILD'S DETAILS

Child's First Name *

Child's Last Name *

Child's Date of Birth *

Gender *The legal sex of the patient. Used for third party claiming.

Address - Street number and name *

Suburb *

Postcode *

State *

Please describe the reason for your enquiry *e.g. areas that you are seeking support for your child or any concerns you may have about their speech and language development.

Do you have any of the funding options below: *

PARENT / GUARDIAN #1 CONTACT DETAILS

Parent / Guardian Full Name *

Phone number *

Email address *

PARENT / GUARDIAN #2 CONTACT DETAILS

Parent / Guardian #2 Full Name

Phone number (2)

Email address (2)

APPOINTMENT PREFERENCES

Please tick all possible locations that you are available to attend ongoing appointments *

Chermside clinic appointmentsKelvin Grove clinic appointments Brisbane mobile appointmentsTelehealth appointments

Please be aware that if you are open to attending more than one location, your wait time for an appointment may be shorter.

If you are open to mobile appointments, please list the possible locations (e.g. home, name of school, kindy, daycare)

APPOINTMENT AVAILABILITY

Select only the days you are available to regularly attend ongoing appointments. **Please be aware that our before and after school appointments are very popular. If you are able to select a larger range of days/times then your wait for an appointment will be shorter.

Please select: *

I ONLY wish to be contacted about appointments that match my above availabilityI wish to be contacted and offered other times if my preferred appointment times aren't available or will require a long wait

Is there anything about your appointment preferences or availability that you would like us to know?

CONSENT

I confirm that above information I have provided is true, complete and accurate.
I give consent for Learn and Grow to contact me via phone, email, or SMS regarding therapy appointments. *

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