Client Registration Form
If applicable, preferred first name
Full date of birth*
Client Contact Information
Relationships Australia can send reminders of future appointments to your mobile or email. If you would like to use this service please tick which option you would prefer.
Email and SMS
Do you have a Centrelink concession card (ie Pension or Health Care Card)?
Pension card expiry
Health care card expiry
Your household income per annum before deductions
$0 - $40,000
$40,001 - $65,000
$65,001 - $80,000
$80,001 - $100,000
$100,001 and over
Your household composition
Single (person living alone)
Sole parent with dependant(s)
Couple with dependant(s)
Group (related adults)
Group (unrelated adults)
Paid work Full time
Paid work Part time
Unpaid work (includes volunteering)
Not working and not looking for work
Unemployed (not working but looking for work)
Studying Full time
Studying Part time
The main language you speak at home*
Your country of birth*
If you were not born in Australia, what date did you first arrive in Australia
If you were not born in Australia, what is your migration visa category
Who referred you to this service?
Child Protection Agency
Community Legal Centre
Family Relationship Centre
Family support service
Aboriginal and/or Torres Strait Islander service
Legal Aid Commission
Mental Health service
Other Family Relationship Service
Other Relationships Australia Service
Private Legal Practitioner
If Yes, what language?
Leave no message
Do not ring work
Do not ring home
Do not send SMS
Do not send email
Do not send promotional material
Telephone or video conferencing services
This is information about our services when offered via telephone or video conferencing. We recommend you read this to familiarise yourself with this process.
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.
Please tick to acknowledge you have read and understood Relationships Australia’s conditions of receiving a service and agree to these terms around your confidentiality and privacy.*