Let Us Help You | Trauma & Relationship Therapy

Client Intake Form

Please fill out the following form to help us understand your mental health needs so that we can match you with one of our mental health professionals.

First Name

Email Address

Last Name

Date of Birth

Will you be paying for services out of pocket or bringing a mental health treatment plan, workers compensation, ICWA, EAP or using private health insurance?

Out of Pocket

With Insurance

If you answered, 'With Worker Compensation, EAP or private health Insurance' please provide your insurance provider's name and your membership number or claim number. Please note that all Workers compensation, & EAP details must be approved and received by us first before treatment can commence.

What brings you to therapy?

Initials

Today's Date

I declare that the info I’ve provided is accurate & complete

Thanks for submitting!

hello@southwesttraumatherapy.com.au

Southwest
Trauma Therapy

Client Intake Form

Get the help you deserve

Address

Contact

Opening Hours