Name *

First Name

Last Name

Date of Birth

MM

DD

YYYY

Parent/Guardian 1 Name

First Name

Last Name

Contact number

(###)

###

####

Parent/Guardian 2 Name

First Name

Last Name

Parent/Guardian status

Couple

Separated

Other (please specify below)

Please be aware that if parents are separated, in most instances both parents' consent is required for the sessions to commence. Are both parents/guardians aware that the child will be attending therapy?

Yes

No

Gender

Male

Female

Non-binary

Other

Preference for sessions

Face to Face

Telehealth

Either

Funding

Private

Medicare

NDIS (self-managed)

Other (specify above)