Contact

Name

First

Last

Preferred name

If different to above

Phone

Mobile phone preferred

Email

Please provide a private email address

Service type requested

Psychological therapy — for myself
Clinical supervision — for myself (a psychologist or provisional psychologist)
Enquiry about therapy or supervision — for someone else

Message

Please share a little about why you’re reaching out and what you’re hoping to achieve in therapy or clinical supervision. If you are enquiring about a service for someone else, please describe that here. Please note, this practice never responds to enquiries marketing a product or service.

Appointment type requested

In-person
Telehealth (phone/video consultation)
Combination of in-person and telehealth

Location

I am based the Northern Tablelands region (Armidale and surrounding suburbs)
I am based in a location other than the Northern Tablelands region (Armidale and surrounding suburbs)

at Spam interest,

Is there a referral from a GP or psychiatrist?

No, I don’t have a referral
No, I don’t have a referral but I plan to get one
Yes, I have a referral

Referral date

Referring doctor's name

Referral type

To identify potential conflicts of interest, please indicate whether you (or the potential client or supervisee if you are enquiring for someone else) are aware of anyone (including friends, family members, colleagues, current or ex-partners) currently or has previously received treatment at this practice.

No
Yes

Please discuss with the psychologist before attending an appointment.

I acknowledge that there are periods during which this psychology practice does not have capacity to accept new referrals. I have checked the Capacity for New Referrals page on the website.

Yes

If the practice has capacity to offer you appointments, please indicate when you would likely be available

Most weeks I am available anytime or most days
My availability is too variable to tell
I can indicate my likely availability for most weeks

Checkboxes

I acknowledge that this private practice does not provide an emergency or crisis service.

Yes

Assessments available at this practice are primarily treatment related. I acknowledge that referrals based solely on the preparation of assessment reports are not accepted (this includes functional capacity assessments; ADHD, ASD assessments; assessments for court or custody matters; firearms applications, NDIS or DVA assessments).

Yes

I acknowledge that treatments provided at this practice are designed for individual adults. Relationship counselling, family counselling, or treatment for children are not available.

Yes

I understand that using this form for other purposes (e.g. marketing or advertising) is not allowed. I am aware that unsolicited commercial communications are prohibited under the Spam Act 2003.

Yes

Contact

Address

Post

Fax

Directions

Access

Services provided

Availability

Get in touch