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

  • In person (Toowoomba QLD): availability June 2026

    Telehealth: immediate availability

  • Are you seeking telehealth or in-person sessions?*

  • Contact details

  • Date of birth*
     - -
  • Pronouns
  • Preferred contact method*
  • Format: (0400000000).

  • 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*

  • 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?

  • 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:

  • Physical and medical conditions

  • Do you experience any of the following?

  • Legal matters

  • Do you have any current legal matters in court? For example family law court, criminal matters.*

  • Further information or questions

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  • How did you hear about NeuroAffirm Psychology?

  • 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.
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