Registration Form - Base

Client Details

Preferred title

First name*

Last name*

If applicable, preferred first name

Full date of birth*

Gender*

If applicable, preferred gender term

Or age

Client contact information

Where you currently live and contact details

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.

Do you consent to being contacted in the future for surveys, research or evaluation exercises?

Yes
No

Income information

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

Yes
No

Pension card expiry

Health care card expiry

Your household income per annum before deductions

Your individual income before deductions

Income frequency

Your main source of income

Relationship and household information

Your current relationship status

Your household composition

Employment status

Client demographic information

Highest level of education/qualification

The main language you speak at home*

Are you Aboriginal or Torres Strait Islander origin?*

Your country of birth*

Migration information

If you were not Born in Australia, please answer the following questions

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

Your ancestry/heritage

Referral information

Method of referral

Self Referral
Manager/HR Referral

Organisational information

Duration of service

Which organisation do you work for?

Which Department/Branch Do You Work at?

Your current employment status

Occupation

What type of Keystart client are you?

Confidentiality and disability

Interpreter required

If Yes, what language?

Please tick if ok to leave message on home phone

Yes

Please tick if ok to leave message on work phone

Yes

Please tick if ok to leave message on mobile

Yes

Disability needs

Intellectual/learning
Psychiatric
Physical
Sensory/speech

I agree that I will not record, in whole or in part, this session.

Yes

I agree that no other unregistered people will be present during the session.

Yes

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.

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.*

Yes

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

Below is important information about your right to 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 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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