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Appointment Request Form
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Name
*
First
Last
Address - Please fill in Line 1, City, State and Zip Code. Please note Zip Code = Postal Code
*
Line 1
Line 2
City
State
Zip Code
Country
Best phone to reach you:
*
Email address:
*
Gender
*
Date of birth
*
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)
Milka (Child, Adolescent & Adult)
Debbie (Child, Adolescent & Adult)
Sasha (Child, Adolescent & Adult)
Sharon (Child, Adolescent, Adult & Couples)
Sarah (Adolescent & Adult)
Do you already have a care plan from your GP?
*
YES
NO
UNSURE
NA
Do you require a phone or a zoom consultation?
*
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).
How did you find out about our clinic?
*
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
Our Promise
Join our Amazing Team
Fees
Meet the Angels
Psychology/Social Work
>
Individual Counselling
Children and Adolescent Counselling
Couples Counselling
How you Can Access Us
Services
Resources
Store
Blog
Contact
Appointment Request form
Change of details
Consent form