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)no 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, Tuesday, Thursday & Friday
8:30 am to 4.30 pm

Wednesday
8:30 am to 7.30 pm

Closed public holidays

Appointment Request

Contact Us

Melbourne Speech Pathology Clinic

Opening hours

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