AAC Professional consultation request

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Thank you for requesting a professional consultation with Two Way Street Director and Speech Pathologist, Janelle Sampson. Professional consultations occur online via Zoom with you and your client and parent/ guardian.

Please only complete this form if you are an Allied Health Professional and are ready to proceed, with consent from your client and/or their guardian(s). If you are still discussing this with them, please read our consultation information, and you can return to complete this form when you are ready to proceed.

The 1 hour consultation will be billed at 2.5 hours to include pre and post follow-up and documentation. Your client's NDIS plan must be plan or self managed to proceed with a consultation.

Before starting this order form, please have the following information ready:

Client's full name
Client's (or parent/guardian) email address

Once we have received this form:

You will be sent a service agreement to complete with your details, information about the client, and invoicing details.
On receipt of the completed service agreement, we will send you a booking link to reserve your online consultation.
The consultation must be attended by yourself, your client, and their support person or family member.
After the consultation, notes with the discussion and recommendations will be sent to you.

Email *

I am the client's Speech Pathologist and I have discussed this consultation and associated costs with them. They have agreed to proceed.

If you have not yet discussed this with your client, please return to complete this form when you have their consent.

Yes

Required

Speech Pathologist's full name: *

Name of organisation:

Contact number: *

Client's full name: *

Client or parent/guardian's email address: *

Client's NDIS plan is: (we are unable to claim for agency managed clients) *

Self managed

Plan managed

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