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Appointment Request

Please submit details here:

for https://speech.mthc.com.au/appointment-request/

"*" indicates required fields

Name*

First

Date of birth

DD slash MM slash YYYY

Address*

Street Address City ZIP / Postal Code

Phone*

Email*

Would you prefer to see the speech pathologist

In person at our clinic

Via telehealth

Hybrid (a combination of in clinic and telehealth services)

Mobile - at home

Mobile - at Kindy

No preference

Client support

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

Yes

No

If "Yes" - what language is required:*

If "Other" - what language is required:*

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

My self (same contact above)

Someone else

Name*

First

Relationship to client*

If "Other" (please specify):*

Address*

Street Address City ZIP / Postal Code

Phone*

Email*

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, etc

Other

If "Other" (please specify):

Optional details (attachment)

Max. file size: 128 MB.

Main medical Diagnosis (if known)

Consent

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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

Melbourne Teaching Health Clinics

Address:
Level 2, 723 Swanston Street
Carlton Victoria 3053
Australia

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