Patient Details

Please share your details below so we can connect you with the right practitioner and arrange your appointment. All information is kept private and confidential.

Your Full Name *

Email Address *

Date of Birth *

Phone Number *

Preferred Contact Method *

Phone
Email
Text
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Best Time to Call (if calling)

Any Time
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How can we help you?

To help us match you with the most suitable clinician, please share a bit about why you are seeking support. The more details you provide, the better we can ensure the right fit. Helpful information includes any symptoms you’ve been experiencing, challenges you may be facing, and the outcomes you hope to achieve from your sessions. If you would prefer to discuss this directly with a member of our team, please indicate that below.

Existing or New Client *

New Client
Existing Client
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Our Specialist *

Psychologist
Counsellor
Psychiatrist
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Reason for Visit *

Are you wanting to book for a formal assessment and report? *

Yes
No
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Appointment Details

Please fill out the details below so we can best accommodate your preferred appointment schedule.

Best time for your appointment *

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Best day of the week *

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Monday
Tuesday
Wednesday
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Friday
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Preferred Appointment Location *

Wooloongabba (in person)
Telehealth
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Type of Visit *

Adult
Child
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Referral Details

Referral Pathway *

How are you paying for your session?

I will be paying for my own sessions privately
GP Referral
NDIS
Self Paying
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Insurance Company
Victims Assist
DVA
EAP
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How did you hear about us? *

Referral from Doctor
Referral from a Friend
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Internet Search
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Upload Referral

Please upload your referral as a pdf, jpg or png file or email directly to [email protected]

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