Name *

Please enter the name of the client who will be receiving therapy, not their guardian.

First Name

Last Name

DOB *

MM

DD

YYYY

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Contact number *

Please enter the phone number you would like to receive all communication, appointment reminders etc.

(###)

###

####

NDIS Plan Start Date *

MM

DD

YYYY

NDIS Plan End Date *

MM

DD

YYYY

Frequency of appointments required *

Weekly

Fortnightly

3 weekly

Monthly

6 weekly

Please select the check-boxes of statements that are applicable to you *

I am aware Thompson Psychology does not bulk bill. I have read the associated costs in the fees section of the website

There is current identified risk such as suicidal ideation or recent in patient treatment facility

There is current pending civil or criminal court proceedings

There is current parenting orders or other family court orders involved

Service delivery preference *

Face to face consultation (Townsville)

Telehealth consultation

Hybrid - a mix of both preferred