New clients (professional form)

My name

My email address

My contact phone number

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

My relationship to the child

Child's name

Child's date of birth

Day

Month

Year

Where child lives

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 this child receives services at Protea Therapy, the family will need to pay the required fee in full on the day of service.

New clients

Are you a professional referring a child to us? Complete the below enquiry form.