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*
Client Contact Information
Street number
Street name
Street type
Suburb/Postcode*
Mobile number*
Landline number
Email address
Other Information
The main language you speak at home*
Your country of birth*
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
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.
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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