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
Appointment Reminders
Relationships Australia can send reminders of future appointments to your mobile or email. If you would like to use this service please tick which option you would prefer.
Please select
SMS
Email
Email and SMS
Other 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*
What type of Keystart client are you?
Please select
Applying for a loan
Current - behind in payments
Current - on time/ahead with payments
Interpreter required
Please select
Yes
No
If Yes, what language?
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
Telephone or video conferencing services
This is information about our services when offered via telephone or video conferencing. We recommend you read this to familiarise yourself with this process.
Read more
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.
Read more
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 confidentiality and privacy.*
Yes