Full Name (Person needing service) *

Phone *

Email *

Are You Aware Of Any Family Members Who Are Seeing A Counsellor At Our Clinic? *

Is this request for you or someone else? *

Name (Person Completing this form) *

Relationship to person receiving service *

Is the client over or under 18? *

Are both parents consenting to service? *

Are there any court orders in place? *

Sex *

Age *

I Prefer To See: *

If Possible I Prefer Counselling To Be: *

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

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