Registration Form - Base

Client Details
Client contact information
Where you currently live and contact details
Appointment reminders
I consent to Relationships Australia WA contacting me at a later date to ask me how I experienced the service.

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

Relationship and household information
Client demographic information
Migration information
If you were not Born in Australia, please answer the following questions
Referral information
Who referred you to this service?




















Who referred you to this service?

















Who referred you to this service?







Method of referral

Organisational information
Confidentiality and disability
Confidentiality needs





Please tick if ok to leave message on home phone
Please tick if ok to leave message on work phone
Please tick if ok to leave message on mobile
Disability needs



I agree that I will not record, in whole or in part, this session.
I agree that no other unregistered people will be present during the session.
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 confidentiality and privacy. Please read this section prior to accessing our services.
Below is important information about your right to privacy. Please read this section prior to accessing our services.
ICIS Fields
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.*
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 see 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.*