Skip to main content
Telehealth
Book Online
About
Our Providers
Billing
COVID-19
FAQ's
Teaching Health Professional Students
News
Services
General GP & Routine Care
Vaccinations & Travel Clinic
Mental Health Support & Psychology Services
Eating Disorders
Pre-Work Medicals
Employment Medicals
Dive Medicals
Pre and Post-natal Care
Skin Checks
Children’s Health & Paediatrics
Health Assessments
Our Clinics
General Practice
Paediatrics
Psychologists
Midwifery
Dietetics
James Cook University Allied Clinics
Physiotherapy
Speech Pathology
Psychology
Chronic Condition Coaching Clinic
Interprofessional Clinic
Occupational Therapy
Allied Health Providers
Referrals
JCU Health Psychology Referral Form
James Cook University Allied Clinics Referrals
Speech Pathology Adult Referral Form
Speech Pathology Paediatric Referral Form
Occupational Therapy Referral Form
Interprofessional Clinic Referral Form
Contact
Home
Referrals
James Cook University Allied Clinics Referrals
Speech Pathology Paediatric Referral Form
Speech Pathology Paediatric Referral Form
Please note, the current waitlist is approximately 6-12 months from the time of referral.
Child’s Details
Full Name
Date of Birth
Home Address
School/Day Care
Grade
Parent/Guardian’s Details
Parent/Guardian 1
Full Name
Email
Phone Number
This field is required
Preferred method of contact
Email
Phone
This field is required
Do you consent to receiving text message appointment confirmations?
Yes
No
Parent/Guardian 2
Full Name
Email
Phone Number
This field is required
Preferred method of contact
Email
Phone
This field is required
Do you consent to receiving text message appointment confirmations?
Yes
No
Reason for Referral: (tick all that apply)
*
This field is required
Speech (producing correct sounds in words)
Expressive Language (vocabulary, grammar and sentence structure)
Receptive Language (understanding spoken instructions, following directions and understanding vocabulary)
Social skills (interacting with peers, social awareness and conversational skills)
Literacy (reading, spelling and/or writing)
Stuttering (repetition of sounds, words or phrases in conversation)
Voice (rough or nasal quality, or often loses their voice in conversation)
Eating or drinking (including sensory preferences)
Other
If Other, please specify
Please describe your concerns and goals
Please specify if your child has an existing medical diagnosis
i.e., disorder, disability or syndrome
If your child has participated in previous allied health services, please specify where and when:
e.g., Speech Pathology, Occupational Therapy, Physiotherapy, Psychology
Please upload any relevant reports/ documentation
Upload File
Book Online
Telehealth
Facebook
