New Clients

Contact Name *

First Name

Last Name

Client Name *

First Name

Last Name

Age of Client *

** please note - we are not currently accepting referrals for children under 10yo **

10-12

12-15

16-20

21-30

31-40

41-49

50-59

60-69

70+

Mode of Appointment *

Would you prefer:

Telehealth

In Person

No preference

Do you have a GP Mental Health Care Plan

No

No - but have booked in with a GP to get one

Yes

Do you have an NDIS plan

*we are unable to see clients under agency managed plans

No

Yes - self managed

Yes - plan managed

Will the service be under WorkCover/Sira

Yes

No

Fees for Service *

I have read and understood that services are not Bulk Billed and will attract a fee as highlighted in FAQ Fees section

Client consent

if you are referring another person:

they are aware I am making the referral

they consent to us contacting them to discuss the referral directly

I am their parent/guardian/carer

Preferred method of contact regarding your enquiry

Email

Phone Call