Thank you for considering Bloom Speech Therapy.

Please note that from January 2025, Bloom Therapy will only be providing assessment and therapy supports to adults requiring the following:

Swallowing Assessment, Review and Mealtime Support: and
Social Communication Assessment and Skill Development

Bloom Therapy is a mobile service and as such, we will need you to identify a suitable space to visit you to undertake your assessment and/or therapy session. This may be your home, workplace, or another space that you are comfortable in.

We would appreciate it if you could provide as much information as possible in the form below so we are able to action your request for services as quickly as possible.

General Information

Client Name *

Client Last Name *

Client D.O.B *

Address assessment or therapy is to take place *

Name of Person Completing This Form *

Contact Email Address *

Contact Phone Number *

Funding

Select the funding arrangement applicable *

Reason for Referral

What are you requesting support in relation to?

Swallowing Assessment / Review or Mealtime SupportSocial Communication Assessment, Support or Skill Development (click here for a list social communication support areas)

Please provide a brief summary of what supports you would like us to provide *(for example - Mealtime Support - coughing on all foods / certain foods, recently discharged from hospital post pneumonia, GP recommended speech pathologist assessment, Social Communication Support - trouble making and keeping friends, difficulties expressing themselves using speech and language, struggling with communication confidence at work / TAFE / day program etc

Diagnoses

Has the client received a formal diagnoses? (e.g.Intellectual Disability, Neurological Condition, Mental Health Diagnosis, Vision Impairment, Hearing Impairment, Autism Spectrum Disorder, Physical Disability etc) *

YesNo

Please provide information regarding diagnoses (if you ticked YES above) *

Current and Historical Behaviours

Does the person engage in, or have a history of any behaviours that may harm themselves or others? Examples include physical aggression, property damage, self-injurious behaviour. *

YesNo

Is there a positive behaviour support plan in place (PBSP)?

YesNo

If YES - we will request a copy of the plan prior to visiting with the client.

Bloom Therapy Fees

Bloom Therapy fees are aligned with the current NDIS price guide rate.

You can access the NDIS price guide here for detailed information.

Bloom Therapy does bill for both direct and indirect therapy services rendered. You will be provided with a service agreement prior to the commencment of any services which will clearly outline details regarding these fees.

Travel fees will be kept to a minimum where possible and where multiple clients within the same geographical area are able to be seen on the same day.

Please check this box to confirm that you have read all information in this form in full prior to your request for service. *

Additional Information

Please provide any other additional information you feel would be useful in relation to your referral.

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