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 Preferred Appointment Type * In-Person Cleveland In-Person Ipswich Telehealth (Video Call/Zoom) Telephone Call 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
