Therapy Enquiry Form

Therapy Enquiry Form

Please complete this form to enquire about therapy services.
Contact details

We will only contact you via your preferred method.
Name*

First NameLast Name
Date of birth*

DayMonthYear
Date
Gender
Other details
she/herhe/himthey/themother
Other
EmailPhone callSMS
Phone number*
Please enter a valid phone number.Format: (0400000000).
Email*
example@example.com
Address*

Street Address

Street Address Line 2

SuburbState

Post code
Are you seeking Telehealth or in-person therapy?
Telehealth video callIn person Toowoomba QLD
Funding details

How are the sessions funded? Note we are currently NOT accepting new clients funded by NDIS, WorkCover, or DVA.
GP Mental Health Treatment Plan referralPrivate paying clientOther
Main challenges you'd like support with:
Understanding autism / ADHDBurnout (autistic/ADHD burnout, workplace burnout, or general exhaustion)Navigating relationships (friendships, romantic, family, workplace)Anxiety or stress (e.g., worry, social, panic, phobia)Low mood, depressionTrauma (e.g., past experiences, family or relationship difficulties, bullying, DV, medical trauma)Emotional intensity or managing emotionsPerimenopauseCommunication or social dynamicsDifficulty starting or completing tasksChallenges with sleep, eating, or maintaining routinesSensory sensitivities or overwhelm (e.g., noise, light, textures, crowds)Shutdowns or meltdownsAdjusting to life transitions (moving, parenting, relationship ending, retirement)Chronic pain and/or illnessOther
Details
Please note:
My focus is on neuroaffirming therapy and assessment for neurodivergent adults. I’m not able to provide support where the main concern is parenting, addiction, personality disorders, OCD, eating disorders, or acute crisis care. If these are your primary needs, I can suggest other services that may be a better fit.
Mental health history
AutismADHDAuDHD (Autism + ADHD)Anxiety (phobia, social, worry, panic)DepressionTraumaOCDTics / Tourette'sBipolarEating disorder (please provide details)Personality Disorder (please provide details)PsychosisSchizophreniaSubstance dependenceGambling dependenceSelf-harmOther
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:
Self-harmThoughts of suicideIntent to suicideA plan to suicideAttempted suicide
Details. For self-harm, please advise how you do this and the severity of injury.
Physical and medical conditions
Chronic painChronic Fatigue Syndrome / Myalgic Encephalomyelitis (CFS/ME)FibromyalgiaReproductive and women’s health concerns (perimenopause, menstrual health, PMDD, endometriosis, Polycystic Ovary Syndrome (PCOS), fertility challenges, etc)Gastrointestinal conditions (IBS, reflux, coeliac disease, Crohn's disease, etc)MigraineEpilepsyHypermobility / Ehlers Danlos Syndrome (EDS)Sleep disorders (insomnia, sleep apnea, circadian rhythm disorders)POTSOther medical conditions (list below)
Details
Legal matters
NoYes
If yes, please provide details:
What do you feel are your strengths, passions, or values that help you in life?
Further information or questions
Is there any other information you would like to provide? Any questions?
Existing reports or documents
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.

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Appointment days - Thursdays and Fridays only

Therapy sessions are currently offered on Thursdays and Fridays only each week. If these days do not suit your schedule, we can provide options for other clinicians who may have broader availability.
In person access needs

For those attending sessions in person, Blanche's consultation room is located up a flight of 15 stairs with a railing. If you need a ground floor access option, please tick below.
I am able to access the consultation room via a flight of 15 stairs with a railing.I require a ground-floor access option for my sessions.
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.
I agree to the collection and use of my personal information in accordance with the Australian Privacy Act 1998 (Cth).
Should be Empty:

Therapy Enquiry Form

Contact details

Are you seeking Telehealth or in-person therapy?

Funding details

Main challenges you'd like support with:

Mental health history

Risk screening

Physical and medical conditions

Legal matters

What do you feel are your strengths, passions, or values that help you in life?

Further information or questions

Existing reports or documents

Appointment days - Thursdays and Fridays only

In person access needs

Privacy Collection Statement