Client Registration Form
Client Details
First name*
Last 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
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
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