Please fill out the following request form to assist us in booking you an appointment with a Psychologist or Counsellor.

Reception will endeavor to contact you within three business days of submitting this request form.

Is this request for you or someone else? *

Are they over or under 18? *

Full Name (Person needing service) *

Age *

Sex *

Contact Phone Number (Mobile Preferred) *

Contact Email Address *

Name (Person Completing this form) *

Relationship to person receiving service *

Are there any court orders in place? *

Are both parents consenting to service? *

I prefer to see *

Are you aware of any family members who are seeing a counsellor at our clinic? *

If possible I prefer Counselling to be *

Do you have a Mental Health Care Plan? (MHCP) *

*Ensure your MHCP includes a signed and dated referral specifying the number of initial sessions up to a maximum of 6 sessions initially. (You can request an additional 4 sessions per calendar year if needed)

Please Briefly Describe Your Reason for Seeing a Counsellor *

I agree to pay a non refundable $60.00 Deposit when booking the First Visit

I understand there can be a wait time of up to 8 weeks (or more) to see a Counsellor

I understand these services are not bulk billed and "out of pocket fees" apply for Medicare Related Services

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