Enquiry Form
This does not guarantee an appointment; however, is designed to assist you in understanding if we're the right practice for your needs.
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (00) 0000-0000.
Funding source:
Medicare
Self-Pay
NDIS
DVA
Other
You acknowledge that sessions can and will be held via telehealth, if appropriate or necessary
Yes
No
In a few sentences, why would you like to see a psychologist?
Have you been diagnosed with or suspect you have the following presenting issues:
*
Personality Disorders
Drug and Alcohol Addiction
Hearing voices or hallucinations
Eating Disorders
Transgender / Transitioning
Court Issues / Report Requests
Cognitive Impairment / Intellectual Disability
Depression
Anxiety and phobias
PTSD, or other trauma
Employment difficulties
Relationship difficulties
Grief and loss issues
Couples therapy
Assessment
None of the above
Other
You acknowledge that our fees are $240/50min session ($232.99 for plan managed NDIS) and confirm that this will be my responsibility.
*
Yes
No
Privacy Policy
*
I have read and accepted the privacy policy
and terms and conditions
Please verify that you are human
*
Save
Submit
Should be Empty: