Request MAP sessions funded by ADAQ

1
What is your Full Name?* This field is required.These details will not be provided to ADAQ unless you explicitly consent for them to be.
First Name
Last Name
2
What is your ADAQ Member Number?* This field is required.Your ADAQ Member Number is between 2 and 5 digits long and can be found by logging into the ADAQ portal or checking your digital membership card.
3
What is your preferred email address for us to contact you on?* This field is required.Please provide the email address you wish to be contacted on by our team.
example@example.com
4
What is your best contact number?* This field is required.Please provide the mobile number you wish to be contacted on to book sessions.
Enter your mobile number in the following format #### ### ###
5
Describe your reasons for wanting to book your EAP session?* This field is required.Share any objectives, issues or situations you'd like assistance with...etc. *This information will only be provided to your practitioner.
Huge
Large
Normal
Small
Ok
Ok
6
What type of session would you like to book?* This field is required.Click the drop down box below and scroll to see all options.
Please Select
Please Select
Counselling
Dietetics & Nutrition
Finance & Money Coaching
Health & Lifestyle Coaching
Meditation & Mindfulness
Workplace Training & Support
Not sure, help me decide
7
Important Note: Waiver Form after submission

After you click the Next button below, complete the verification and click "Submit".

You will be redirected to a digital Waiver Form. It's essential that you complete this Waiver Form and retain the PDF copy that will be sent to your email address.

Prior to booking your first session, your nominated Practitioner will request a copy of this signed Waiver form.
8
Please verify that you are human* This field is required.
Should be Empty: