Appointment Request

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Client biographical details

First Name (required): Last Name (required):

D.O.B. (required):

Residential Address:

Street Address (required): Street Address 2:

Suburb (required): Postcode (required):

Phone Number (required): Email Address (required):

Would you prefer to see the speech pathologist in person at our clinicvia telehealthhybrid (a combination of in clinic and telehealth services)Mobile - at homeMobile - at Kindyno preference

Client support

Is an interpreter required to communicate with the client/parent and/or the client’s legally appointed medical decision maker? YesNo

If "Yes" - what language is required:

If "Other" - what language is required:

Who do we contact to arrange an appointment (primary contact)?

First Name: Last Name:

Relationship to client

If "Other":(please specify)

Contact Postal Address:

Street Address: Street Address 2:

Suburb: Postcode:

Phone Number: Email Address:

Preferred contact method

Contact details:

If "Other":(please specify):

First Name: Last Name:

Phone Number: Email Address:

Referral reason: Swallowing assessment and management (including: challenges with eating/ drinking/ taking medications/ saliva management)Communication assessment and/or management (including: difficulty with understanding speech/ following instructions, fluency challenges, difficulty thinking of the right words, difficulty physically pronouncing the words, challenges in reading/writing, difficulty with verbal problem solving / planning, etcOther

Optional details Optional details (attachment) Main medical Diagnosis (if known)

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Contact Us

Melbourne Speech Pathology Clinic

Level 1, 723 Swanston St,
Carlton 3053
Phone: 03 9035 7199
Fax:03 9347 1535
Email: speech-clinic@unimelb.edu.au

Opening hours

Monday - Friday 8:30 am to 4.30 pm

Closed public holidays

Appointment Request

Contact Us

Melbourne Speech Pathology Clinic

Opening hours

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