Client Registration Form
Client Details
Preferred title
Please select
Mr
Mrs
Ms
Miss
Master
Dr
Prof
First name*
Last name*
If applicable, preferred first name
Full date of birth*
Gender*
Please select
Male
Female
Non-Binary
[I/They] use a different term
Prefer not to answer
If applicable, preferred gender term
Client Contact Information
Street number
Street name
Street type
Suburb/Postcode*
Mobile number*
Landline number
Email address
Appointment Reminders
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.
Please select
SMS
Email
Email and SMS
Other Information
Do you have a Centrelink concession card (ie Pension or Health Care Card)?
Yes
No
Pension card expiry
Health care card expiry
Your household income per annum before deductions
Please select
$0 - $40,000
$40,001 - $65,000
$65,001 - $80,000
$80,001 - $100,000
$100,001 and over
Your household composition
Please select
Single (person living alone)
Sole parent with dependant(s)
Couple
Couple with dependant(s)
Group (related adults)
Group (unrelated adults)
Homeless/no household
Employment status
Please Select
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
Caring
Parenting
The main language you speak at home*
Are you Aboriginal or Torres Strait Islander?*
Please select
Aboriginal
Torres Strait Islander
No
Both
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
Please select
Humanitarian
Skilled
Family
Other
Your ancestry/heritage
Who referred you to this service?
Advocacy/Support group
Centrelink
Child Protection Agency
Community Legal Centre
Community organisation
Corrective services
Employer
Family Court
Family Relationship Centre
Family support service
Family/Friend/Neighbour/Partner
Health Practitioner
Aboriginal and/or Torres Strait Islander service
Internet
Legal Aid Commission
Mental Health service
Other Family Relationship Service
Other Relationships Australia Service
Private Legal Practitioner
School
Self
Interpreter required
Please select
Yes
No
If Yes, what language?
Confidentiality needs
Leave no message
Do not ring work
Do not ring home
Do not send SMS
Do not send email
Do not send promotional material
Disability needs
Intellectual/learning
Psychiatric
Physical
Sensory/speech
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.
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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.
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Please tick to acknowledge you have read and understood Relationships Australia’s conditions of receiving a service and agree to these terms around your privacy.*
Yes