Client Registration Form
Client Details
Gender*
Please select
Male
Female
Non-Binary
[I/They] use a different term
Prefer not to answer
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
Do you consent to being contacted in the future for surveys, research or evaluation exercises?
Yes
No
Other Information
Your household composition
Please select
Single (person living alone)
Sole parent with dependant(s)
Couple
Couple with dependant(s)
Group (related adults)
Group (unrelated adults)
Homeless/no household
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*
If you were not born in Australia, what date did you first arrive in Australia
If you were not born in Australia, what is your migration visa category
Please select
Humanitarian
Skilled
Family
Other
Your ancestry/heritage
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.
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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 confidentiality and privacy.*
Yes