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
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
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.*