Appointment Request Form
Complete the confidential form below and a member of our experienced team will be in contact within one business day.
Your information is kept securely in compliance with The Privacy Act 1988
Receptionist Notes:
What type of appointment are you looking for?
Adult Individual
Adolescent Individual
Child Individual
Couples Therapy
Relationship Therapy
Are you looking for a particular therapy or approach?
Please Select
ISTDP
EMDR Therapy
Schema Therapy
CBT
DBT
Mindfulness
Other
Do you have a strong preference for face to face or Telehealth appointments?
Face to Face
Telehealth
No preference
Are you seeking an appointment urgently?
Urgently
I am able to wait a few weeks
Do you want to be offered appointments at short notice?
Yes
No
Are you planning to have a third party assist with appointments fees?
Medicare
Private Health Insurance
Worksafe/Workcover
NDIS
Employment Assistance Program (EAP)
Other
Name
*
he/him
she/her
they/them
other
Pronouns
First Name
Last Name
Email
*
Please enter a valid email address.
Phone Number
*
Please enter a valid phone number
Do you have a preference for how we contact you?
Phone Call
SMS
Email
No Preference
On a scale of 1-5 - how motivated are you to undertake therapy and address emotional difficulties right now?
Not Motivated
1
2
3
4
Very Motivated
5
1 is Not Motivated, 5 is Very Motivated
Is there anything else you would like us to know at this stage?
Do you have a strong preference about your therapist's gender?
No Preference
Female
Male
Are you specifically seeking ISTDP?
Yes
No
Would you like to be offered lower-cost appointments?
Yes
No
What you are seeking help with?
What type of appointment are you looking for?
Adult Individual
Adolescent Individual
Child Individual
Couples Therapy
Relationship Therapy
Family Therapy
Other
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