Speech Pathology Referral Form

Please complete this document when referring for Speech Pathology Services.

If you would like any assistance with completing this form, please contact our Client Relationship Team on 8379 6976.

Referrer Information

Name of individual completing referral form *

Relationship to client (e.g. self, parent, support coordinator, etc.) *

Email address *

Client Information

Client name *

Preferred name (if different)

Date of Birth *

Pronoun

he/himshe/herthey/themother

terminology preferences

autistic/autistic personperson with autismperson on the spectrum/autism spectrumother

please specify *

Primary Phone number *

Primary contact email address *

Primary contact name *

Diagnosis, medical conditions and/or allergies *

Does the client/care team require an interpreter? *

YesNo

If yes, which language?

Booking Preferences

Upon receipt of the completed referral form, unless we need to discuss any of your responses with you first, our Client Relationship Team will develop a Service Agreement for you based on the answers you provide. These are typically blocks of 24hrs, however, assessments alone may be less hours. The agreement will be sent for your approval, and once approved you will be ready to be offered a suitable vacancy when it arises.

Please provide the below information to assist us in creating your agreement.

Will you be using NDIS funding or paying Fee for Service (out of pocket)? *

NDISFFS

If NDIS, how much funding are you able to allocate for this service? *

Please upload your NDIS plan here.

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NDIS Number *

Plan Start Date *

Plan End date *

Plan Nominee (responsible person for making decisions about NDIS services on the behalf of the individual)

My Improved Daily Living budget is: *

Self-ManagedPlan-ManagedAgency-Managed

Plan Manager Name *

Plan Manager email address *

Is this a PACE plan

Yes No Unsure

Location Preferences (select all that apply)

Home Suburb *

School/Kindy Name *

Day Options (Name and Location) *

If other, please detail *

Day and Time Preferences (click 'add another preference' to add multiple days and times)

Please Note: Autism SA only provides weekly blocks of therapy support.

Speech Pathology Support Type

What support are you requesting? *

Speech Pathology Assessment and ReportBlock of therapy support (i.e. sessions) to learn new skills and receive supportive strategies and recommendations

Speech Pathology Assessment and Report *

For an assessment to determine current communication skills which may include assessing speech, language, literacy and functional communicationTo determine the need for speech pathology support or for NDIS plan review (funding recommendation for speech pathology support)To trial a range of Augmentative and Alternative (AAC) devices to determine a suitable option for the individualOther (please specify)

Specify Other *

Block of therapy support (i.e. sessions) to learn new skills and receive supportive strategies and recommendations *

The individual has not previously received speech pathology supportThe individual has received speech pathology support more than 1 year agoThe individual has received speech pathology support within the past 12 months

The individual has received speech pathology support within the past 12 months *

A report can be providedA report is unable to be provided

Please upload any previous speech pathology assessment or progress reports:

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Background Information

Please describe the individuals current living situation: (e.g. lives independently, lives with others, lives with family and level of support provided) *

How does the individual currently communicate (please tick all that apply): *

High-level language use as expected for their ageSpoken language (phrases and sentences)Spoken language with limited ability to use language functionally to get needs metNon-speakingUses gestures/body language to communicateUses AAC (e.g. visuals, communication boards, AAC device)

Further comments

Does the individual currently receive any other professional or Allied Health supports? (select all that apply)

If other, please detail:

If receiving Speech Pathology services currently, please provide details below:

Speech Pathologist name:

Provider/Agency:

Does the client display behaviours of concern? (Please note: this is to allow us to best allocate and support the individual within Speech Pathology) *

NoYes

Does the individual have a current Positive Behaviour Support Plan? *

NoYes

Please provide a copy of the plan *

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Please specify other:

Do any of the following apply to the client?

Under Guardianship of the MinisterFoster family/alternative care arrangementCourt orderVoluntary out of home care / supported independent living2:1 support requirement

Any other information that you would like to attach:

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Focus Areas for Speech Pathology Support

Please select all areas that you would like further assessed and/or supported through Speech Pathology services.

What areas would you like Speech Pathology Support to focus on? *

Understanding and Use of Language *

Following instructionsUnderstanding and responding to questionsSharing thoughts, ideas and feelingsLearning what words mean / develop their vocabularyImproving their ability to form sentencesUsing the correct grammar and word tense

Further comments

Speech *

Learning to say some soundsSpeaking more clearly e.g. can be difficult to understand what is being said (e.g. speaks using a fast pace)Developing age-appropriate speech patterns e.g. when substituting one sound for another e.g. ‘g’ for ‘d’ (gog instead of dog)

Further comments

Augmentative and Alternative Communication (AAC) *

Learning to be a more effective communication partnerLearning about the individual's AAC deviceSupporting the individual to use their AAC device

Further comments

Social Communication and Interaction *

Learning about personal spaceHaving a back-and-forth conversationUsing appropriate language for the contextLearning strategies to help with accepting winning/ losingUnderstanding feelings and emotions in themselves/ othersDeveloping skills required to form and sustain friendshipsLearning to self-advocate

Further comments

Literacy *

Developing reading abilityDeveloping ability to spell wordsDeveloping written communication skills, such as writing stories, or messaging others

Further comments

Voice and Fluency *

Using an appropriate volumeTalking fluently and finding the correct words to sayCoordinating breathing and talking

Further comments

Cognition and Thinking *

Problem solving skillsSequencing tasks and do things in the ‘correct’ orderMemory and developing strategies to help remember informationRecalling words when communicating with others

Further comments

Thank you for completeing the referral form. Please review your answers and click submit.