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Your Name *

First Name

Last Name

Preferred Service *

Telehealth (by Zoom videoconference or phone)

Face-to-Face in Ipswich

Face-to-Face in Gympie

Who is the appointment for? *

Me

Someone else

Client's Name

If you're booking for someone else, please provide the client's full name

First Name

Last Name

Client's Age *

18+ years

13-18 years

12 years or under

Do you have a referral from a GP? *

A referral is required if you wish to claim a rebate.

Yes

Not yet

No, I won't be claiming a Medicare rebate

Will you be using any of the following funding methods?

NDIS

WorkCover

Private Health Insurance

Other Third Party, e.g. Victim Assist, Child Safety

None

Preferred method of contact *

Please select all that apply

Phone call

Text message

Email