New Client Enquiry Form

Please complete this form with all relevant details to ensure that we can meet your needs.

Once the form is received, we aim to get back to you within 1-2 weeks.

Please note that our after-school appointments (3 pm onwards) are currently fully booked. If you require an after-school appointment time, you will be added to our waitlist.

Client Name

First Name

Last Name

Age

Contact Name

For children, adolescents, or clients managed by a third party.

First Name

Last Name

Email address

Phone number

(###)

###

####

Client Consent

If you are completing this form on behalf of the client

The client is aware that I am making this referral

I am the parent/carer/guardian of the client

The client would like to be contacted directly (provide their contact details above)

The client consents for me to be contacted on their behalf

Desired services

What service are you wanting to access?

Reason for Referral

Current concerns, symptoms, or challenges

Background Information

Previous diagnoses, engagement with services, treatments, or any other relevant circumstances.

Goals

What are you hoping to gain from psychological therapy or assessment?

Please select the option that best applies to your situation

Please note for Medicare clients - the Medicare rebate does not cover the full fee for services. See the FAQ section for more information.

Preferred Days/Times

We operate on Wednesdays, Thursdays, and Fridays (telehealth only).

Preferred mode of services

Fees

I understand that Cup of Tea Psychology is not a bulk billing service and that fees apply.

How did you hear about us?