Client Registration Form
Full date of birth*
Client Contact Information
Do you consent to being contacted in the future for surveys, research or evaluation exercises?
Your household composition
Single (person living alone)
Sole parent with dependant(s)
Couple with dependant(s)
Group (related adults)
Group (unrelated adults)
The main language you speak at home*
Are you Aboriginal or Torres Strait Islander?*
Torres Strait Islander
Your country of birth*
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
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.
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.
As a parent/guardian, I agree on behalf of a young person under 18 years
By typing my name I acknowledge I have read and understood Relationships Australia’s conditions of receiving a service and agree to these terms around confidentiality and privacy.*