Client Registration Form

Client Details
Client Contact Information
Appointment Reminders
Do you consent to being contacted in the future for surveys, research or evaluation exercises?

Other Information
Do you have a Centrelink concession card (ie Pension or Health Care Card)?

Who referred you to this service?




















Confidentiality needs





Disability needs



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.
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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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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.*