Child Referral Form

Childs Name:
Date of Birth:
Age:
Sex:
School / Preschool: 
GP / Doctor:
NHI Number (if known):
Parents / Guardians:
Address:
Town / City:
Email:
Phone:
Communication concerns (please provide detail of difficulty/problem):
Previously seen by another SLT service? (please provide detail)
How did you hear about GIANT LEAPS Speech Therapy?

 

PRIVACY STATEMENT: GIANT LEAPS Speech + Language Therapy collects personal information about their clients to support their assessment and therapy, and to ensure that effective services are provided. Information may be shared with other specialists and professional 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 you if you do not. You have the right to request access to, and correction of personal information held by GIANT LEAPS Speech + Language Therapy at any time.

Privacy Permission:

TERMS AND CONDITIONS: 

CONFIDENTIALITY: All information shared with GIANT LEAPS Speech Therapy is private and confidential. You may request access to any written information about your child at any time. 
PAYMENT FOR SERVICES: GIANT LEAPS shall issue invoices for the charges to the Client on the 30th of the month. Payment is required by to 20th of the following month or by agreement with the company. Payment plans will be considered at the written discretion of the the company. For all account queries contact account@giantleaps.nz
NON-ATTENANCE FEE: If you fail to attend, cancel or seek to reschedule an appointment with less than 24 hours’ notice a 50% non-attendance fee will be charged:
TRAVEL + MILEAGE: Travel and mileage charges will apply to all assessment and therapy services outside of the clinic location.  

PLEASE READ OUR COMPREHENSIVE TERMS + CONDITIONS HERE

Agreement: