Client Registration Form
Client Details
Gender*
Please select
Male
Female
Intersex
Non-Binary
First name*
Last name*
Full date of birth*
Client Contact 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*
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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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 privacy.*