Fill out our intake form to begin SLP therapy.

Note: WBSLP’s books are currently at capacity and we are not accruing a waitlist. Please send a message to hear back from a WBSLP regarding possible wait times or alternative options.

Parent/Caregiver's Name

First Name

Last Name

Phone

Address

Participant's (Child's) Name

First Name

Last Name

Date of birth

Main concerns

Pregnancy and Birth

Duration, any complications e.g. jaundice, breathing difficulties

Previous Intervention

e.g. Speech, OT, Psychology

Has the participant seen a Paediatrician in the past 12 months?

If yes, give details: (name of paediatrician, outcome)

Has the participant's vision and hearing been tested?

What and when were the results?

How will the participant's therapy be funded?

Please email plan to widebayspeechlanguageplay@gmail.com

Plan-Managed (I will provide my Plan Manager's contact details)

Self-Managed (I will provide my NDIS plan)

I don't have NDIS (I am private paying)

I will be using Medicare (I have an EPC).

If you are Plan Managed, what is your Plan Managers contact details?

What school or early learning service does the participant attend?

What are your preferred times/day/location for therapy

Location examples include home, school/daycare. We will do our best to accommodate these.

Any additional comments?