Clients name:
D.O.B: Age: Sex: male female
Referral date:
Referral by: (e.g. mother, teacher, GP, self)
Address:
Parents / Guardians:
Phone: (home) (work) (mobile)
Email:
School / Preschool:
Teacher:
Previously seen by another SLT service (please provide details)
Communication concerns (Description of the difficulty / problems)
PRIVACY STATEMENT:
GIANT LEAPS Speech + Language Therapy collects personal information about children and young people to support their learning and ensure that effective services are provided. Information may be shared with your child’s school, early childhood education provider, pediatrician, and other specialist agencies necessary for the provision of our effective services. It is not compulsory for you to provide any personal information but we may not be able to provide the most effective services for your child if you do not. You and your child have the right to request access to, and correction of personal information held by GIANT LEAPS Speech + Language Therapy at any time.
Please choose one of the following options:
I GIVE permission for GIANT LEAPS Speech Therapy to access information about my child from other relevant agencies, organisations and specialists.
I DO NOT give permission for GIANT LEAPS Speech Therapy to access information about my child from other relevant agencies, organisations and specialists.
