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
Suburb/Postcode*
Mobile number*
Do you consent to being contacted in the future for surveys, research or evaluation exercises?
Yes
No
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*
Your ancestry/heritage
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.*
Yes