Registration Form
Who is completing this form?
*
First Name
Last Name
Relationship to Child:
*
Email
*
example@example.com
Mobile Number:
*
Please enter a valid phone number.
Format: 0400 000 000.
Child's Name:
*
First Name
Last Name
Child's Date of Birth:
*
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
Child's Gender
Please Select
Male
Female
Another term (please specify)
Child's Primary Address:
Street Address
Street Address Line 2
City
State / Region
Postal / Zip Code
Does your child have a diagnosis?
Yes
No
In the process
What is the main reason you are seeking play therapy?
*
What is your preferred play therapy session schedule? (Current availability in-clinic at Weston Creek)
Monday afternoon (between 1:00 pm to 3:30 pm)
Tuesday afternoon (between 1:00 pm to 3:30 pm)
What is your preferred contact method when a spot becomes available?
Email
Phone - I would like to book a complimentary 15-minute phone consult prior to committing to therapy sessions (phone consults are done every Mondays only)
Either
How did you hear about us?
Google search
Facebook group
Word of mouth
GP/other allied health professional
Other
How will sessions be funded?
Privately (no external funding)
NDIS Plan Managed
NDIS Self Managed
Other
Have you seen a different allied health specialist before?
Yes
No
Anything else we should know about or any information you would like to share?
Newsletter Preferences
I would like to receive occasional updates, resources, and information from Canberra Play Therapy by email. I understand I can unsubscribe at any time.
I prefer not to receive any newsletter updates
Submit
Should be Empty: