Request An Appointment Name * First Name Last Name Preferred Name Phone * (###) ### #### Email * Date of Birth * MM DD YYYY Client Drivers Licence Number (if requesting a driving assessment)Number Are you a current or returning client of Mind Life Clinic? * Yes No Do you have a family member or friend that attends Mind Life Clinic * Yes No Service * Individual Psychology / Therapy / Counselling Occupational Therapy Social Work Assessment EMDR Therapy Group Workshop Method of funding * Medicare rebated sessions with a GP referral Self-funded with Private Health rebate Fully self-funded Department of Veterans Affairs (DVA) National Disability Insurance Scheme (NDIS) WorkSafe TAC VOCAT Employee Assistance Program (EAP) Other (please specify) Would you prefer face-to-face or telehealth appointments * Note that often the wait times are less for telehealth appointments, there is also additional flexibility with session times for telehealth appointments. Face-to-face Telehealth I don't have a preference Would you prefer a male or female clinician * Female Male I don't have a preference Please provide any additional information required to link you with a suitable clinician Deposit * Mind Life Clinic requires a deposit for all new client appointments. The deposit is due within 48 hours of booking an appointment and can be paid online or over the phone. Please note that we are unable to hold appointments without a deposit for new clients. I agree Cancellation Policy * Mind Life Clinic has a very strict cancellation policy. Any client who “no-shows” or cancels within 24 hours of their appointment will be charged a $90 fee (or $50 if your appointment was with a Provisional Psychologist). No further appointments will be permitted until the cancellation fee has been paid. I agree Thank you for submitting an appointment request. We will aim to contact you within 48 hours.
