Referral - Online Speechie

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REFERRAL

Online Speechie Clinic

What age range is your child?

0-2 years 3-4 years 5-9 years 10-13 years 14+ years

What services are you seeking?
Choose any that apply

Ongoing speech/language therapy Speech/language assessment only (not for autism) Autism diagnostic assessment only (some advice on other diagnoses e.g. ADHD, intellectual, learning etc)

Does your child have a diagnosed disability?

Yes No Other

You selected other for question above, please tell us more about your child diagnosed disability

What is your child diagnosed with?

Autism Global developmental delay (GDD) Language delay/disorder Speech sounds delay/disorder ADHD Dyslexia Anxiety Depression Obsessive compulsive disorder Behavioural diagnosis Other None

Does your child have an NDIS plan?
(national disability insurance scheme)

Yes No

How is your NDIS plan managed?

Self managed Plan managed NDIA managed Others

Upload your NDIS plan

How does your child communicate? Choose all that apply to your child
For me to understand what level of communication your child is at.

Mainly non-verbal/no words Using mainly single words - imitating only, no independent Using mainly single words independently Starting to put two words together in sentences (e.g. go car, up daddy)) Using mainly 2 word phrases, trying to say longer sentences Using sentences to communicate independently Older - conversational language

What are you mainly concerned about? (select any)
i.e. what are the main difficulties your child has/that you want help for?

Talking/expressive language Speech clarity Stuttering Reading Writing/spelling Understanding/comprehension Social skills/interaction with others

What difficulties does your child have?
Choose any that apply

Speaking words (currently not saying much at all) Speaking in short phrases (e.g. with 2 or 3 word sentences) Speech clarity (difficult to understand) Understanding what I say (i.e. instructions I give them, questions I ask) Engaging with adults Engaging with other children

How much do YOU understand your child?
This relates to the clarity of your child's speech

Always Usually Sometimes Rarely Never

How much do IMMEDIATE FAMILY MEMBERS understand your child?
This relates to the clarity of your child's speech

Always Usually Sometimes Rarely Never

How much do EXTENDED FAMILY MEMBERS understand your child?
This relates to the clarity of your child's speech

Always Usually Sometimes Rarely Never

How much do ACQUAINTANCES/OTHER KIDS understand your child?
This relates to the clarity of your child's speech

Always Usually Sometimes Rarely Never

How much do EDUCATORS understand your child? (if applicable)
This relates to the clarity of your child's speech

Always Usually Sometimes Rarely Never

Does your child have difficulties adapting to new people or new environments? This helps us prepare for the initial appointment.

Always Usually Sometimes Rarely Never

Does your child have difficulties engaging or adapting to familiar people who visit?E.g. extended family, family friends? This helps us prepare for the initial appointment.

Always Usually Sometimes Rarely Never

Does your child have difficulties engaging with children their age?E.g. with visitors, at the park, play dates, parties etc. This helps us prepare for the initial appointment.

Always Usually Sometimes Rarely Never

Does your child take more than a few minutes to calm down once upset/angry/emotional?
E.g. difficulty regulating their emotions seems to need more time than typical to settle/feel better. This helps us prepare for the initial appointment.

Always Usually Sometimes Rarely Never

On average, how often does your child have moments of being significantly upset?
E.g. this could be crying or shouting, but could also be withdrawing, shutting down or persistently refusing. This helps us prepare for the initial appointment.

Once a week 2-3 times a week 4 -5 times a week Once a day 2-3 times a day 4 or more times a day

Please describe your child's main difficulties and any other comments

What past or present professionals have raised their concerns about your child showing autistic or other disorder traits?

Speech pathologist Occupational therapist Day care staff School teacher Psychologist Paediatrician GP Other

Please state the full names of any health professionals involved in your child's development

Please summarise what the professional has shared with you regarding their concerns about your child. If applicable, include any concerns around autism, ADHD, or other developmental disorders.

What professionals are you seeking to do the autism assessment?
Eligibility for NDIS and school support in WA requires at least TWO professionals to confer with the diagnostic decision. Either a speech pathologist (sp) + clinical psychologist (cp) OR Paediatrician+ SP/CP. If you are not booked in with a paediatrician or CP, you will need to select SP+CP.

Speech pathologist Clinical psychologist Speech pathologist + clinical psychologist

What days are you available for attending the first initial assessment appointment?
Choose ALL that you can possibly attend. Standard services are available Mondays, Tuesdays and Thursdays only. Autism assessments are usually scheduled on Fridays only.

Tuesday Thursday Friday

Please upload any relevant documents, reports etc.
This will assist with determining what assessments have and have not been done and will further inform assessment time & pricing. Optional (e.g. assessment reports, letters or NDIS plan).

Your first & last name (parent/caregiver)

Your phone/mobile
So we can discuss your concerns and determine whether the O.S clinic is right for you and your child.

Your Email (parent/caregiver)
So we can send you our clinic information pack & appointment availability.

What's your postcode?

Child's First Name

Child's Last Name

Child's date of birth
Required to determine what assessment tools your child is eligible for.

Does your child attend school or daycare?

No Yes daycare part time Yes Pre-kindy Yes Kindy Yes primary school Yes high school

More information
Other concerns, questions? What are you looking for in regards to therapy? Regularity, day, assessment etc.

How did you find out about the Online Speechie clinc?

Instagram/social media - I have been following you for a month or more My friend shared one of your social media posts and I then followed you/enquired Word of mouth - a friend/family/professional recommended you Google search engine Google maps app AI chat Other

Please state the friend or professional who recommended us (or their organisation)
This helps use return the favour and thank them for their recommendation 🙂

Helping parents feel confident and capable in growing their child’s communication – without stress, guilt, or extra time. Because early support matters – and no parent should have to wait for help.

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