New clients (parent form) | Protea Therapy

My name

My child's name

My child's date of birth

Day

Month

Year

My email address

My contact phone number

If listing a landline, please include your area code; for example, 03 7034 6944

Where my child and I live

Please note that:

Protea Therapy only provides speech pathology services to children under 12 years of age.
Protea Therapy only provides speech pathology services to children and families in Australia.
Protea Therapy only accepts payments on the day of service. This means that we are unable to accept clients who have agency-managed or plan-managed NDIS funds.

I understand and agree that if my child receives services at Protea Therapy, I will need to pay the required fee in full on the day of service.

New clients