New Client Therapy Enquiry Submit the form below and a member of our team will contact you shortly Client's Name * First Name Last Name Date of Birth * MM DD YYYY Is client a minor? * Yes No What is the main reason you are seeking support? * Anxiety Depression Grief PTSD Relationship Difficulties ADHD/Autism Support OCD General Stress Eating Concerns Addiction Other Please briefly describe any other concerns you have Is client also interested in/in need of assessment in addition to therapy? Yes No If client is a minor, contact persons name First Name Last Name Email * Home Phone (###) ### #### Mobile Phone * (###) ### #### Address Address 1 Address 2 City State/Province Zip/Postal Code Country Your available days for appointments Monday Tuesday Wednesday Thursday Friday Your available times for appointments Early mornings Mornings Afternoon Evening Other Are you flexible? Yes No Which best describes your funding situation? Privately funded Medicare funded (MHCP) Private Health fund Third Party Other/Unsure If you are third part funded, are you funded by: NDIS WorkCover Employer Insurer Other/Unsure If you are Medicare funded (MHCP), do you currently have your MHCP from your Medical Doctor? Yes No If yes, date of MHCP and number of sessions remaining available: Where did you hear about Evolve Wellbeing Psychology? Thank youA member of our team will be in touch with you shortly
