Your History

Your Child's History

We are excited to welcome you to Hear and Say! So we can best help you and make the most of your upcoming session please complete the below form.

Tell us a bit about you

What service are you interested in?

Speech pathologyHearing testOccupational therapy (Brisbane only)

What brings you to Hear and Say?

Child's Details

Child's first name *

Child's last name *

Preferred name (if different)

Pronouns (optional)

Date of Birth *

Age in years (calculated)

Gender *

MaleFemaleIndeterminate / intersex / unspecified

Parent/Guardian/Carer Details

Preferred contact first name *

Preferred contact last name *

Preferred name (if different)

MumDadCarerGuardian

Pronouns (optional)

Preferred phone number *

Preferred email address *

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Your Child's History

Did your child pass the Newborn Hearing Screening? *

YesNoN/A

Were there complications with the pregnancy or at birth for the child? *

YesNo

If yes, please provide further details *

Does your child have a history of ear infections? *

YesNo

If yes, one ear or both ears? *

Has your child ever had grommets or perforated eardrums? *

YesNo

If yes, please provide further details *

Is there a family history of permanent hearing loss? *

YesNo

If yes, please provide further details *

Has your child had a hearing test? *

YesNo

If yes, what were the results *

If possible, please attach their hearing test results

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Are there any concerns from your child's school or daycare regarding their hearing, speech or development? *

YesNoN/A

If yes, please provide further details *

Do you have any concerns about your child's hearing, speech or language? *

YesNo

If yes, please provide further details *

Do you have any concerns about your child's general development? *

YesNo

If yes, please provide further details *

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Is your child on any medication? *

YesNo

If yes, please provide further details *

Has your child been unwell recently? *

YesNo

Do you or your family speak another language other than English at home? *

NoYes

If yes, please specify and list the other languages that are spoken

What would be the preferred or dominant language that your child uses to communicate currently?

Will you require an interpreter when accessing our services?

NoYes

If yes, please indicate which language

Is there a history in your family of speech, language, feeding, social communication or other difficulties related to your concern? *

NoYes

If yes, please provide further details

Educational details

Does your child currently attend any educational settings? *

NoYes

Name of current Educational Setting (please indicate Grade level if applicable)

Is your child currently receiving additional educational support? *

NoYesNot applicable

If yes, please specify the support being received

Do you have concerns regarding your child’s cognition, attention or memory? *

NoYes

If yes, please provide further details

Has your child been diagnosed with any illnesses/disorders or disabilities? *

NoYes

If yes, please provide further details

It is strongly recommended that you provide copies of previous reports for your child by email to mail@hearandsay.com.au or upload below, for your Speech Pathologist to review at least 24 hours prior to your upcoming appointment.

Please upload copies of previous reports for your child

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Additional Details

NDIS funding

Does your child have National Disability Insurance Scheme (NDIS) funding? *

NoYes

What is your child's NDIS number?

Is your child

Self-managedPlan-managedNDIA-managed Would rather not say

What is the name of your Plan Manager?

What is the start date of your NDIS plan?

What is the end date of your NDIS plan?

If Other, please specify

Communications

If other, please specify

Payment of fees

I agree that the client/parent/guardian is responsible for the payment of all fees for service provided by Hear and Say. Any information needed for the payment of these fees through NDIS, Medicare or privately will be provided to the client/parent/guardian at the time of billing. It is expected that all fees will be paid on the day of service. *

I want to receive information about offers, services, products, events, and fundraisers that Hear and Say thinks may be of interest to me or surveys including by mail, email, SMS, social media, or other forms of communication. I understand I can unsubscribe from these communications at any time.

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Research Consent

We work in collaboration with world-class researchers to advance our knowledge and provide the evidence-base to underpin our work and improve outcomes of children and families.

By indicating my consent and signing this form, I grant permission for the following general research-related activities that have been approved by the Hear and Say Research and Ethical Advisory Committee:

Access to my child’s medical, speech, language and hearing data that are documented in my child’s file.
Data sharing of my child’s results between projects.
Data sharing with First Voice, a national and global alliance of which Hear and Say is a member.

In doing so, I understand that:

No identifying information regarding my child or myself will be divulged; that any data collected will not be published or presented as to reveal our identity; and our privacy will be maintained at all times.
Our participation is completely voluntary and that I may terminate our involvement in the studies at any time, without this affecting my child’s ongoing enrolment at the Hear and Say.
Although the purpose of the research projects is to improve the quality of services for children with hearing impairment, our involvement in the research may not result in any direct benefit to my child.
Separate consent will be sought from me for inclusion in any research projects requiring active participation by me and/or my child.
I have the opportunity to raise any particular concerns relevant to the participation of my child and/or myself in research and to request project updates.

I grant permission for general research-related activities that have been approved by the Hear and Say Research and Ethical Advisory Committee.I do not give research consent.

Telepractice Consent

Under certain circumstances, Hear and Say may offer the opportunity for telepractice-based (online) consultations instead of in-person with a clinician.

We will not provide personal information to any other individuals or organisations without prior consent except where required by law to do so. At times, we may also disclose information on a confidential basis with:

Your clinician/specialist must maintain confidentiality and privacy standards during sessions, and in creating, keeping and transmitting records.
At times, audio and video recordings of sessions may be taken to support the clinician/specialist’s work, as may occur in centre-based consultation. You will be informed before a recording takes place and can refuse to be recorded for any reason. Your clinician/specialist will inform you of the reason for the recording and how it will be stored and used.
While your clinician/specialist is obligated to meet standards to protect your privacy and security, telecommunication, including videoconference, may increase exposure to hacking and other online risks; as with all online activities, there is no guarantee of complete privacy and security protection. You may decrease the risk by using a secure internet connection, meeting with your clinician/specialist from a private location, and only communicating using secure channels.
You can ask about alternatives to telepractice at any time. If you refuse or change your mind about telepractice services, your clinician/specialist can discuss any other options with you. Your clinician/specialist may or may not be able to offer alternative services.

I agree to receive services via telepractice as applicable. I understand that I may agree or refuse any service or part of a service at any time. I can agree or refuse in writing or verbally.I do not give telepractice consent.

Photos and Videos Consent

I give permission for Hear and Say and affiliates to take photographs and/or video recordings of my/our child and siblings, and myself/ourselves during events and activities organised or provided by Hear and Say. I understand that the photographs and/or video recordings may be used and published by Hear and Say and their partners (e.g. at our events) on platforms which may include our website, social media, press releases, reports, resources and collateral, and funding agreements.I do not give photos and videos consent.

Sharing of Information Consent

Hear and Say is committed to ensuring the protection of your personal information. The following summary outlines how we collect, handle, store, and disclose your personal information, in accordance with applicable privacy laws and best practice standards.

1. Collection, Use, and Disclosure of Personal Information

We will collect, hold, and use your personal information to provide you with relevant services, including but not limited to:

Early Intervention (Listening and spoken Language Therapy)
Audiological (Hearing) Management
Medical Management
Allied Health Services
Rehabilitation/Habilitation
Speech Pathology
Group programs
Associated Administrative Purposes (such as external auditing)

We may collect personal information from external providers as part of the above services.

2. Protection of Personal Information

We take reasonable steps to ensure that your personal information is protected from misuse, interference, and loss, as well as unauthorised access, modification, or disclosure.

3. Disclosure of Personal Information

We will not provide your personal information to any other individuals or organisations without your prior consent, except where required or authorised by law. However, we may disclose personal information on a confidential basis to the following parties:

Contractors: We may share information with contractors who assist Hear and Say with services such as database management, printing, and mailing.
Overseas Recipients: In certain situations, we may disclose your information to overseas recipients, for example, a medical practitioner in another country, if you are using our health services and reside outside Australia.
Emergency Services: In the event of an emergency, we may disclose your personal information to relevant emergency services personnel.

4. Your Rights

You have the right to request access to your personal information and to ask for it to be corrected if it is inaccurate, out of date, incomplete, or misleading.

5. Consent

I give permission to collect and share personal information with the relevant parties involved. I understand, acknowledge, and agree to be bound by the terms set out in this form. *

I give permission for this information to be shared/distributed via email. *

I acknowledge that I have read the Privacy Policy. *

Full name *

Signature *

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Date *

Your Child's History

Tell us a bit about you

Child's Details

Parent/Guardian/Carer Details

Your Child's History

Educational details

Additional Details

NDIS funding

Communications

Payment of fees

Subscribe

Research Consent

Telepractice Consent

Photos and Videos Consent

Sharing of Information Consent

1. Collection, Use, and Disclosure of Personal Information

2. Protection of Personal Information

3. Disclosure of Personal Information

4. Your Rights

5. Consent