Optimum Health Solutions

Speech Assessment Onboarding

Client Details

Requesting an appointment for *

MyselfSomeone else

Title

Date of Birth *

First Name *

Last Name *

Phone Number (Mobile) *

Gender *

Email *

Street Address *

Suburb *

State *

Post Code *

Language *

EnglishNon-English SpeakingRequire an Interpreter

Referrer Details

Referrer Name *

Phone Number *

Email Address *

What is your role?

I am a GP, Doctor or SpecialistI am an NDIS LAC or Support CoordinatorI am an NDIS Plan ManagerI am a Parent, Guardian or Caregiver.

Company Name

Check out our current capacity and waitimes here

Click here for availabilities

Preferred Location

Home / School / Telehealth

Please add school or address of alternate location where services will be provided *

Risk Assessment (Safety & Home Access Information)

Type of Dwelling: *

Is there Parking available? *

Are there any Occupational Health and Safety issues on the Property to note? *

If 'other' is selected above, please provide further details *

Does the Participant have a known history of verbal or physical abuse *

Are there any triggers we should be aware of? *

Any external agencies indicating significant concerns with home/family environment *

Are there any animals on the property? *

is there adequate mobile phone reception on the property? *

Is the client aware and happy for us to be coming to the home? *

Is there a requirement for a Carer or Support Worker to be present at the time of the appointment? *

Is there any other information that you would like to make the therapist aware of before going out? *

Funding Stream - Please select below

Funding Stream

I am an NDIS ParticipantI will be paying Privately

NDIS

Please attach a copy of your current NDIS Plan

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A copy of your plan will be provided to the practitioner to enable us to better understand your needs and provide a more tailored service.

NDIS Plan Number *

NDIS Plan Start Date *

NDIS Plan End Date *

Diagnosis *

Is your Plan a PACE Plan? *

YesNo

How to Endorse OHS

Please note Endorsement must be completed prior to initial appointment.

Support Coordinator Details

Do you have a Support Coordinator? *

YesNo

Support Coordinator Name: *

Phone *

Support Coordinator Email:

Please select a Speech Assessment below

Click here to view what is included in our Speech Assessments

Please select an assessment below *

Communication Assessment - Gold = $3150Communication Assessment - Silver = $2730Diagnostic Dyslexia Assessment = $3570Swallowing & MTMP Assessment - Gold = $3150Swallowing & MTMP Assessment - Silver = $2730

Please select an assessment below *

Communication Assessment - Gold = $2909.85Communication Assessment - Silver = $2521.87Diagnostic Dyslexia Assessment = $3297.83Swallowing & MTMP Assessment - Gold = $2909.85Swallowing & MTMP Assessment - Silver = $2521.87

What category is your funding for Speech Assessments being drawn from? *

Improved Daily Living (CB Daily ActivitiesDaily Activities (CORE)

How is your Speech Therapy Assessments funding Managed? *

Agency ManagedPlan ManagedSelf Managed

Speech Assessment Total

Plan Manager

Who is your Plan Manager? *To ensure we can process your service agreement efficiently, please make sure all the information provided is accurate. If you do not have all the required information at the moment, you can select “Save and Continue.” A copy of your form will be emailed to you, allowing you to complete it later once you have gathered all the necessary details. Please only submit the form when all information is correct

Contact Number

Email address for invoicing *

Plan Manager Calculation

Communication Consent

How did you hear about us?

Please select if you would like to receive:

How did you hear about us?

SMS - Reminders

Recommendation

SMS - Marketing

Google

Email - Reminders

Existing Client

Email - Marketing

I received an email

Other

Total Agreement Amount

Total Amount

I have read and agree to the terms and conditions *

I have read and consent to the Cancellation Policy *

Additional Information

Any additional information you wish to provide to your allocated Practitioner?

Any Additional Documentation

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e.g Previous assessments, Medical summary etc..

Public Guardian Authorisation

I have a Public Guardian in place

Public Guardian Email address

Authorisation and document signing

I am authorized to sign on behalf of the participant (you may be required to provide evidence of authorisation)

I do not have permission to sign on behalf of the participant

If you do not have permission to sign on behalf of the participant:

Populate the signatories email address below.

Please select 'Save and continue' below (it's right at the bottom of the form in orange and can be hard to see!) .

A window will pop up and prompt you to enter the email for the authorised signatore.
Enter email of signatore and press send.
Please note there will be no submit button until the form is signed.
Signatory will receive a link via email to the completed form for them to sign.

Email address of Authorised Signatory *If the authorised signatory does not have an email address, enter an alternative email address and make arrangements with the participant to sign. i.e support coordinator, guardian, referrer.

Name of the person signing *

Signature *

Draw signature|Type signatureClear

Please note that without a signature we can not schedule an appointment and the form will be returned for signature to the correct party for signing.

Date *

Blacktown, Campbelltown, Cessnock, Croydon Park , Sylvania, Hornsby, Nowra - ABN - 76 128 542 236

Liverpool - ABN - 57 637 316 511

Batemans Bay - ABN - 77 643 773 111

Goulburn - ABN - 58 615 423 446

Dodges Ferry, Moonah, Mornington, Brisbane - ABN - 27 606 845 498

North Rocks - ABN - 30 678 552 782

Save and Complete Later