Client Registration Form
Full date of birth*
Client Contact Information
Do you consent to being contacted in the future for surveys, research or evaluation exercises?
The main language you speak at home*
Are you Aboriginal or Torres Strait Islander?*
Torres Strait Islander
Your country of birth*
Which organisation do you work for?
Your current employment status
Duration of service
0 - 4 years
5 - 9 years
10 - 19 years
20 years or more
Method of referral
Who referred you to this service?
Leave no message
Do not ring work
Do not ring home
Do not send SMS
Do not send email
Do not send promotional material
Below is important information about your right to confidentiality and privacy. Please read this section prior to accessing our services.
Client information & confidentiality
Client Information and Confidentiality explains how we will treat your confidential information. We recommend that you read this prior to your session. If you are unclear about anything please ask your practitioner when you meet with them.
Privacy and your information
Relationships Australia is committed to your right to confidentiality and privacy. This information details the conditions of receiving a service from Relationships Australia WA.
As a parent/guardian, I agree on behalf of a young person under 18 years
By typing my name I acknowledge I have read and understood Relationships Australia’s conditions of receiving a service and agree to these terms around confidentiality and privacy.*