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Appointment Request Form
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Name
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First
Last
Address - Please fill in Line 1, City, State and Zip Code. Please note Zip Code = Postal Code
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Line 1
Line 2
City
State
Zip Code
Country
Best phone to reach you:
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Email address:
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Gender
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Date of birth
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Appointment type
*
Individual Counselling
Couples Counselling
Naturopathy
Massage
Reflexology
Who is this appointment for?
*
Child
Adolescent
Adult
Do you have a preferred Therapist or Clinician?
*
No
Michelle (Adult, Couples & Coaching)
Tania (Child, Adolescent & Adult)
Milka (Child, Adolescent & Adult)
Debbie (Child, Adolescent & Adult)
Sasha (Child, Adolescent & Adult)
Sharon (Child, Adolescent, Adult & Couples)
Nicci (Massage & Reflexology Therapist)
Do you already have a care plan from your GP?
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YES
NO
UNSURE
NA
Do you require a phone or a zoom consultation?
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Yes
No
Unsure
If you have a compromised immune system, are self-isolating for suspected CONVID-19, over 70 yrs, or over 50 yrs and identify as an Aboriginal or Torres Strait Islander, are pregnant, or is a parent of a child under 12 mths, then you are still able to be seen though via Phone or Video (Zoom app).
If seeing the Naturopath, is this a:
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Initial Appointment
Follow Up Appointment
1/2 Hr Acute Care appointment
If wanting to see the Masseuse, is if for..
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Full Body Massage (60 mins)
Indian Head Massage (20-30 mins)
Reflexology (60 mins)
Other
How did you find out about our clinic?
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Online Search
Google Ads
Facebook
Other Social Media
Referred by family/friend
Referred by Health Practitioner
Flyer/Brochure
Other
If other please add details below:
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Do you have any questions or concerns?
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Submit
Home
About
Meet the Angels
Services
>
Psychology/Social Work
>
Individual Counselling
Children and Adolescent Counselling
Couples Counselling
How you Can Access Us
Our Promise
Join our Amazing Team
Fees
Resources
Store
Blog
Contact
Appointment Request form
Change of details
Consent form