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
Other Information
Your current relationship status
Please select
Single or never married
Married
De facto
De facto separated
Separated but not divorced
Divorced
Widowed
Other relationship
N/A - person aged under 15 years
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*
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
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