Client Registration Form
Client Details
Gender*
Please select
Male
Female
Intersex
Non-Binary
First name*
Last name*
Full date of birth*
Suburb/Postcode*
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
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*
Your ancestry/heritage
Below is important information about your right to privacy. Please read this section prior to accessing our services.
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.
Read more
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