Welcome to Hear and Say – please complete the below form.
Here are a couple of handy hints to note when filling out this form:
- Some questions have a plus/minus to the right hand side to add additional lines (e.g. significant other question).
- Some questions asked throughout might seem detailed however are related to research. Child's details Child's name (Required)
Date of birth (Required) Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Month 1 2 3 4 5 6 7 8 9 10 11 12 Year 2024 2023 2022 2021 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 Parent/carer details Parent/carer one: Name (Required)
Relationship to child (Required) Please select Mother Father Grandparent Carer Other Parent/carer one: Level of education (Required) Would you like to list a second parent/carer? (Required) Parent/carer two: Name
Parent/carer two: Level of education Consent Clinical
*Please note, this consent is required to ensure we can undertake clinical services at Hear and Say.
Hear and Say is committed to the protection of your personal information. The following is a summary of how we collect, handle, store and disclose your personal information.
We will collect, hold and use your personal information (including from external providers) to provide you with the relevant services related to early intervention, audiological management, medical management, allied health services, habilitation and for associated administrative purposes, including external auditing.
We will not provide personal information to any other individuals or organisations without prior consent except where required by law to do so. At times, we may also disclose information on a confidential basis with:
Contractors who provide services, for example, database management, printing and mailing to Hear and Say. Overseas recipients, such as a medical practitioner, about an individual if they are using our health services and they reside outside Australia. Emergency services in case of an emergency. See more Clinical (Required) Getting Involved: Photos and Videos Photos and Videos (Required) Telepractice-based consultations
Under certain circumstances, Hear and Say may offer the opportunity for telepractice-based (online) consultations instead of in-person with a clinician.
We will not provide personal information to any other individuals or organisations without prior consent except where required by law to do so. At times, we may also disclose information on a confidential basis.
Your clinician/specialist must maintain confidentiality and privacy standards during sessions, and in creating, keeping and transmitting records. At times, audio and video recordings of sessions may be taken to support the clinician/specialist’s work, as may occur in centre-based consultation. You will be informed before a recording takes place and can refuse to be recorded for any reason. Your clinician/specialist will inform you of the reason for the recording and how it will be stored and used. While your clinician/specialist is obligated to meet standards to protect your privacy and security, telecommunication, including videoconference, may increase exposure to hacking and other online risks; as with all online activities, there is no guarantee of complete privacy and security protection. You may decrease the risk by using a secure internet connection, meeting with your clinician/specialist from a private location, and only communicating using secure channels. You can ask about alternatives to telepractice at any time. If you refuse or change your mind about telepractice services, your clinician/specialist can discuss any other options with you. Your clinician/specialist may or may not be able to offer alternative services. See more Telepractice consent Research
We work in collaboration with world-class researchers to advance our knowledge and provide the evidence-base to underpin our work and improve outcomes of children and families.
By indicating my consent and signing this form, I grant permission for the following general research-related activities that have been approved by the Hear and Say Research and Ethical Advisory Committee:
Access to my child’s medical, speech, language and hearing data that are documented in my child’s file. Data sharing of my child’s results between projects. Data sharing with First Voice, a national and global alliance of which Hear and Say is a member. Access to my child’s NAPLAN results, including access to his or her writing script, if available.
In doing so, I understand that:
No identifying information regarding my child or myself will be divulged; that any data collected will not be published or presented as to reveal our identity; and that our privacy will be maintained at all times. Our participation is completely voluntary and that I may terminate our involvement in the studies at any time, without this affecting my child’s ongoing enrolment at the Hear and Say. Although the purpose of the research projects is to improve the quality of services for children with hearing impairment, our involvement in the research may not result in any direct benefit to my child. Separate consent will be sought from me for inclusion in any research projects requiring active participation by me and/or my child. I have the opportunity to raise any particular concerns relevant to the participation of my child and/or myself in research and to request project updates. See more Research (Required) Hearing information Did your child pass the Newborn Hearing Screening? (Required) Newborn Hearing Screening Result Newborn Hearing Screening Result cont. (Required) Please select Bilateral refer Bilateral pass Unilateral right refer Unilateral left refer Diagnostic Hearing Test Result (e.g. ABR) (Required) Hearing loss details
Left ear Please indicate the level of hearing loss your child has in their left ear. Please select Within normal range Mild Moderate Severe Profound Other Please indicate the type of hearing loss your child has in their left ear. Please select Conductive Sensorineural Mixed
Right ear Please indicate the level of hearing loss your child has in their right ear Please select Within normal range Mild Moderate Severe Profound Other Please indicate the type of hearing loss your child has in their right ear Please select Conductive Sensorineural Mixed Do you know the cause of your child's hearing loss? Please select the cause of you child's hearing loss Please select Auditory Neuropathy Spectrum Disorder (ANSD) Chemotherapy Cytomegalovirus (CMV) Connexion 26 Genetic Large Vestibular Aqueduct Syndrome (LVAS) Microtia/Atresia Mondini Other/unknown Additional details Name of best school contact
Year level Please select Prep Year One Year Two Year Three Year Four Year Five Year Six Year Seven Year Eight Year Nine Year 10 Year 11 Year 12 Child's cultural heritage (Required) Child's Immunisation Status Please select... Immunisation up-to-date Not immunised/ immunisations not up-to-date Unsure Do you speak any languages other than English at home? Language(s) other than English spoken to the child Please indicate any legal arrangements in place regarding your child's care (e.g. DVO, Custodial Arrangements, etc) Please provide a brief birth and medical history of your child including recent significant medical events. Describe your goals for the assessment/treatment session Please upload any relevant files including ABR's, audiograms, school reports etc. NDIS details Does your child have National Disability Insurance Scheme (NDIS) funding? (Required) Is your child eligible for NDIS? What is the start date of your NDIS plan? What is the end date of your NDIS plan? How is your NDIS plan managed? Please select Self-managed Agency-managed Plan-managed Would you like someone from our NDIS team to contact you? Healthcare details Medicare details Australian Hearing Service Card Are you a member of a Private Health Fund? Private Health Fund details Device information
Please indicate what, if any, type(s) of hearing devices your child wears. Hearing aids Left ear Right ear Cochlear implants Left ear Right ear Does your child have a wireless communication device? (e.g. personal FM system) Personal FM system receiver Please select Phonak Roger X Phonak Roger 20 (Cochlear N7) Phonak Roger 14 (Cochlear N6 and N5) Phonak Roger 17 (Advanced Bionics Naida) Phonak Roger 21 (Med El Sonnet/ Sonnet 2) Phonak My link (neck loop) Phonak MLx Integrated into hearing aid Personal FM system transmitter Please select Roger Pen Roger touchscreen mic Phonak Inspiro Phonak RemoteMic Cochlear MiniMic2+ MedEl AudioLink Phonak MLx Oticon Medical Mic and Streamer Does your child use his/her FM system? Does your child have a soundfield system? Please select which soundfield system your child has Provider details Hearing Australia Ear, Nose and Throat Specialist (ENT) Paediatrician Ophthalmologist (eye specialist) General Practitioner Advisory Visiting Teacher Speech Pathologist Other Medical Professionals Other agencies involved in care of your child (e.g. childcare, school etc.) Communications How did you hear about us? Subscribe