Client Registration Form

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

Other Information
Who referred you to this service?

Disability needs

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.
Read more
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.
Read more
As a parent/guardian, I agree on behalf of a young person under 18 years