Appointment Request Form
Complete the confidential form below and a member of our experienced, empathetic team will be in contact within one business day.
Appointment Details:
Your information is kept securely in compliance with The Privacy Act 1988
Receptionist Notes:
What you are seeking help with?
Are you looking for a particular therapy or approach?
Please Select
ISTDP
EMDR Therapy
Schema Therapy
CBT
DBT
Mindfulness
Other
What type of appointment are you looking for?
Adult Individual
Adolescent Individual
Child Individual
Couples Therapy
Relationship Therapy
Family Therapy
Other
Are you seeking an appointment urgently?
Urgently
I am able to wait a few weeks
Do you want to be offered appointments at short notice?
Yes
No
Do you have a strong preference for face to face or Telehealth appointments?
Face to Face
Telehealth
No preference
Are you planning to have a third party assist with appointments fees?
Medicare
Private Health Insurance
Worksafe/Workcover
NDIS
Employment Assistance Program (EAP)
Other
Name
*
First Name
Last Name
Email
*
Please enter a valid email address.
Phone Number
*
Please enter a valid phone number
Do you have a preference for how we contact you?
Phone
SMS
Email
No Preference
Is there anything else you would like us to know at this stage?
Are you specifically seeking ISTDP?
Yes
No
Please select your preference of therapist
Female
Male
No Preference
Would you like to be offered lower-cost appointments?
Yes
No
Save
Submit
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