Book A Consultation


Complete this form to book a consultation with one of our qualified Speech Pathologists or Occupational Therapists. After you complete this form a member of our admin team will be in touch within 1 business day to discuss your needs.

Client Booking Form













We aim to match you with a therapist who is available at a time that is convenient for you. Giving a wider range of preferred days / times makes it more likely that a therapist will be available sooner. 

Children will normally need to be present for at least part of the session. In some cases it may be possible to arrange appointments through a child's school.










Contact Details










Parent / Guardian Details

Client Details




Address





Other Details




Concerns



Other Services

Previous Reports or Assessments


If there are any previous reports or assessments you would like to share with us please upload them here. If you have already shared these documents with us you do not need to upload them again.

Key Contacts
Please provide details of any other people you would like us to coordinate with. This could include:
  • Support Coordinator
  • Key Worker
  • Allied Health Assistant
  • Teacher
  • GP
  • Paediatrician
  • Social Worker
  • etc

Key Contact Details
Click "Add another response" at the bottom of the page to add more contacts.







Medicare & Insurance


NDIS Funding Details

If your funding is managed in more than one way please select the way your Capacity Building funds are managed.



NDIS Plan

Please upload a copy of your NDIS plan if you are comfortable sharing it. Providing a copy of your NDIS plan is completely optional. Seeing your plan will help us to understand your goals, and we can give you advice on the most effective way to use your available therapy budget.

If you have already provided us with a copy of your NDIS plan you do not need to upload it again.

Who should we send invoices to for payment?
Invoices will be sent after each session to be paid within 7 days.




Consent to Exchange Information
Umbo clinicians may need to exchange information about your disability, injury or medical illness with other agencies to provide them with the occupational therapy and/or speech therapy services that they need.

By submitting this form I give my permission for information about my disability, injury or medical illness to be obtained from and exchanged between Umbo and the aforementioned agencies (as applicable) so that Umbo clinicians can provide me with the occupational therapy and/or speech therapy services that I need.

I understand that my rights will be respected and all personal information obtained will be kept confidential in a password-protected file.

My worker has discussed with me how and why certain information about me may need to be provided to other service providers.


I further understand that a fax/photocopy/digital copy of this authority will be considered as valid as the original. I understand I can remove or change this authority at any time.

This Authority will remain valid for 12 months or until I revoke or change this authority.