Therapy Enquiry Form

Therapy Enquiry Form

Please complete this form (takes approx. 5 mins) to enquire about therapy services.
Content note: This form includes questions about mental health, including experiences of distress, self-harm, and suicidal thoughts. Some questions may feel sensitive or difficult.

Please note NeuroAffirm Psychology does not provide crisis or emergency support. If you are in immediate danger or need urgent assistance, please contact:Emergency services: 000, Lifeline: 13 11 14 (24/7 crisis support), or Beyond Blue: 1300 22 4636
Current availability
Telehealth: immediate online availability

In person Toowoomba: not currently taking new referrals
Are you seeking telehealth or in-person sessions?
Contact details
Name

First NameLast Name
Date of birth

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
Gender
Other details
Pronouns
Other
Preferred contact method
Phone number
Please enter a valid phone number.Format: (0400000000).
Email
example@example.com
Address

Street Address

Street Address Line 2

SuburbState

Post code
Funding details

How will your sessions be funded? Note we do not accept NDIS, DVA, or WorkCover referrals.
Main challenges you'd like support with:
Select all options that apply

Other
Details
Please note:
We are not able to provide support where the main concern is eating disorders, psychosis, pr. schizophrenia. If these are your primary needs, we can suggest other services that may be a better fit.
Mental health history
Do you have any past or current diagnoses, or do you personally identify with any of the following experiences?

Other
Details
Risk screening

To determine if you are suitable for waitlisting, please indicate if you have experienced any of the following within the past 30 days:
Details. For self-harm, please advise how you do this and the severity of injury.
Physical and medical conditions
Do you experience any of the following?
Details
Legal matters
Do you have any current legal matters in court? For example family law court, criminal matters.
If yes, please provide details:
Further information or questions
Is there any other information you would like to provide? Any questions?
Do you have any existing reports or documents relevant to the service you are seeking? For example, psychiatrist, psychologist, OT, speech and language therapy reports.

Cancelof
How did you hear about NeuroAffirm Psychology?

Other
Newsletter option: would you like to be added to NeuroAffirm's mailing list to receive occassional newsletters, resources, and updates?
Privacy Collection Statement

NeuroAffirm Psychology values your privacy and complies with the Australian Privacy Act 1988 (Cth). We collect personal information, such as your name, email, and message, when you submit our contact form. This information is used to respond to enquiries and provide support. By submitting the form, you agree to this collection statement.
Please indicate your consent below:
Should be Empty:

Therapy Enquiry Form

Content note: This form includes questions about mental health, including experiences of distress, self-harm, and suicidal thoughts. Some questions may feel sensitive or difficult.

Current availability

Contact details

Funding details

Main challenges you'd like support with:

Mental health history

Risk screening

Physical and medical conditions

Legal matters

Further information or questions

Privacy Collection Statement