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
Client Contact Information
Street number
Street name
Street type
Suburb/Postcode*
Mobile number
Do you consent to being contacted in the future for surveys, research or evaluation exercises?
Yes
No
Other Information
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*
Duration of service
Please select
0 - 4 years
5 - 9 years
10 - 19 years
20 years or more
Family Member
Which Department/Location do you work at?
Method of referral
Self Referral
Manager/HR Referral
Who referred you to this service?
EAP brochure
HR
Colleague
Supervisor/manager
Staff briefing
Website/intranet
Self
Family/friend
Disability needs
Intellectual/learning
Psychiatric
Physical
Sensory/speech
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.
Read more
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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As a parent/guardian, I agree on behalf of a young person under 18 years
Yes
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.*