New Client Web Enquiry Form

“Welcome to Therapy Matters, a leading centre for clinical excellence in speech pathology for over 25 years, where we strive to make a difference so our clients can flourish and lead happy, connected and communicative lives. Our team currently provide therapy that matters to over 350 children and young adults across the Gold Coast and Northern NSW. In order to help you become part of this community, the first step is to find out a bit more about you so we can match you and your child to the best therapist.”

Tania Teitzel (Director)

About You & Your Child

What are you concerned about? *

Child’s First Name *

Child's Surname *

Age *

Parent First Name *

Parent’s Surname *

Home Postcode

Phone Number *

Alternate Phone Number

Email (Verification Required) *

Send code

School

Does your child have a diagnosis or disability?

YesNo

Please describe

What type of funding do you have?

NDISPrivate (Independently fund)Medicare ReferralOther

How is your NDIS managed

Self ManagedPlan ManagedAgency Managed

What Medicare referral do you have?

CDM (Chronic Disease Management) (was EPC) - up to 5 sessions per yearAboriginal & Torres Strait Islander (ATSI) - up to 5 sessions per yearASD or Other Disabilities - up to 20 therapy sessions per lifetime

Please specify Other Funding

Matching Matters

WHY have your chosen our clinic to meet your child’s needs?

WHEN can you attend appointments?

Any time, we’re flexible & keen to get startedParticular times

Other preferences

PLEASE NOTE: We can experience periods of high demand for our services. There may be a waiting time for some services. It can be difficult to provide exact timelines as there are many factors to consider. Our team works very hard using our Matching Matters Pathway to help us manage our waiting list as fairly, empathetically and responsively as possible. The more information you give us about your needs and the more flexible you are in the service you want, the easier it is for us to meet your needs sooner.

If we have no availability immediately, are you happy to wait?

YesNo

WHERE would you like the service?

Please specify Other Service

PLEASE NOTE: Weo nly provide dedicated on-site school services to the following schools. Approval required by Therapy Matters Director and School Principal for visits to any other schools (pending therapist availability).

*In QLD*	*In NSW*
Silkwood School Somerset College The Southport School (Preschool & Preparatory)	St Joseph's South Murwillumbah Mt St Patrick Primary & College St Anthony's St James

WHAT are you seeking?

It's our FIRST TIME seeing a speech pathologistWe've been to THERAPY MATTERS before and need more helpWe've seen ANOTHER speech pathologist before and are seeking a change

We have past reports available?

YesNo

WHO are you looking for?

We take great care and time in selecting the speech pathologists on our team. While we are confident that your child would be in great hands with any of our therapists, we understand that sometimes, your child may need a therapist with a particular skill set or temperament. We know that this can be important to families so we welcome your input as part of our Matching Matters process. While we try our best to consider your wishes, should you request a particular therapist, they may not always have availability or there might be a long wait for their services. We have a large team to choose from and we are confident that there will be one match or more within our team to meet your child's needs.

What kind of therapist are you looking for?

Are you interested in a particular therapist, if they are available?

YesNo

Name of therapist

HOW did you find out about our clinic?

Please specify

Please let us know if it was someone special who recommended you to us, we'd love to give them thanks

PRIVACY INFORMATION COLLECTION STATEMENT

Therapy Matters collects information in this form about you/your child for the primary purpose of finding the most appropriate appointment match to meet your needs. We will only collect as little information as is absolutely necessary to understand your appointment needs. Once you decide to be a client with us and place your trust in us, we may ask you to share more comprehensive background on your child to further refine our matching process as part of us building a comprehensive picture of your child in order to best help them with next steps. We will always let you know at each step of the way how we are respecting your privacy.

Information that you provide in this form will be protected securely in our cloud platforms protected by multifactor authentification and accessed only by members of our Therapy Matters team. Therapy Matters takes all reasonable steps to ensure that information collected about you/your child is protected, accurate, complete and up to date. You may have access to your/your child’s information on request and if you believe that any of the information is inaccurate, we may be able to amend it accordingly. We retain your child's information for as long as necessary to provide a service and for the time periods required by state legislation for the keeping of child health records.

You may contact Tania Teitzel (Clinic Director & Privacy Officer) at Suite 6, 43 Tallebudgera Creek Rd West Burleigh, or by emailing info@therapymatters.com.au, or by calling 0755207860 if you have any concerns or queries about our privacy collection processes.

For further Information on how Therapy Matters collects, protects and stores your personal information please see our complete Privacy Policy - Therapy Matters

I have read, understood and accept Therapy Matters Privacy Policy *

Thank you for completing this form.

Our friendly Client Services Team will make contact with you

as soon as possible to match a service to your needs.

We look forward to helping you.

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