Assessment Form - Clearlytalking

A ABOUT YOU

Assessment #

Name:

Home Address:

Suburb:

Postcode:

Phone:

Mobile:

Occupation:

Business Name/Type:

Highest Level of Education:

Email:

Were you born in Australia? YesNo

Date of birth:

Country of origin (if not Australia):

Years in Australia:

Who do you live with?

B MEDICAL ISSUES

Known Medical Issues:

Medications:

Do you get vocal fatigue? NoYes

Known vocal impediments:

How often do you get sore throats?

Have you ever lost you voice?

Do you Smoke? NoYes

How many per day?

Have you smoked in the past? NoYes

When was the last time you smoked?

C LANGUAGE & VOCAL SKILLS

Languages spoken, indicate fluency
*Score out of 10
1 = Beginner,
10 = Expert

Language	*Spoken Fluency	*Reading Fluency	*Written Fluency	Spoken at Home?
				Yes
				Yes
				Yes
				Yes

IELTS or Similar Scores

What do you think are your main problems with your accent?

D HOME & SOCIAL LIFE

Social activities
(What do you do in your spare time)

Reading habits

Film & Television Habits

Radio Habits

How much time do you spend speaking your mother tongue?

E YOUR PRIMARY OBJECTIVES

What are your primary objectives in working with a voice coach?

F COMMUNICATION OPTIONS

USING EMAIL May we use email to communicate with you (send coaching plans, arrange appointments, send invoices etc). Preferred YesNo

NEWSLETTER Please subscribe me to your regular newsletter & information service (receive member benefits) YesNo

CONTACT How did you find out about us?
Who referred you?

PRIVACY STATEMENT Clearly Talking respects the confidence you have in giving us sensitive private information about yourself.
• We only gather the information we require to be able to do our job effectively.
• You have the right to withhold information which you do not feel is relevant. However if you do so please be aware that it may hinder our ability to give an accurate assessment.
• We do not sell or pass on your information to others without your express permission.
• We take all reasonable precautions in protecting your privacy either on or off line.
• We will only use your email address to communicate with you as you have given us permission.

G MEDICAL & GENERAL DISCLAIMER

DEFINITIONS Clearly Talking refers to Clearly Talking its agents and employees.

NO ADVICE Clearly Talking may discuss general information about medical conditions and treatments. The information is not advice, and should not be treated as such.

LIMITATION OF WARRANTIES The medical information discussed by Clearly Talking is provided “as is” without any representations or warranties, express or implied. Clearly Talking makes no representations or warranties in relation to the medical information discussed.
Without prejudice to the generality of the foregoing paragraph, Clearly Talking does not warrant that:
• The medical information discussed will be constantly available, or available at all; or
• The medical information discussed is complete, true, accurate, up-to-date, or non-misleading.

PROFESSIONAL ASSISTANCE You must not rely on the information discussed as an alternative to medical advice from your doctor or other professional healthcare provider. If you have any specific questions about any medical matter you should consult your doctor or other professional healthcare provider. If you think you may be suffering from any medical condition you should seek immediate medical attention. You should never delay seeking medical advice, disregard medical advice, or discontinue medical treatment because of information discussed by Clearly Talking.

LIABILITY Nothing in this medical disclaimer will limit any of our liabilities in any way that is not permitted under applicable law, or exclude any of our liabilities that may not be excluded under applicable law.

DECLARATION I, the undersigned, have read the medical disclaimer and understand that Clearly Talking and its agents offer no medical advice.
I also agree that the information provided by me in this form is accurate and provided in good faith for the purposes of an assessment of my voice and related work.

Name:

Signed:

Dated: