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The Mind Room: New Client Waitlist
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* Indicates required question
Email
*
Your email
First Name
*
Your answer
Last Name
*
Your answer
Contact Phone Number
*
Your answer
Your residential postcode (Australia) or Country (international)
Your answer
Your age range:
Under 18 years
18-29 years
30-40 years
41-50 years
50+ years
Clear selection
What is the reason for your booking? Select at least one option:
*
Clinical - Mental illness concerns eg. anxiety, depression, PTSD, disordered eating
Clinical - Life stress, change or transition
Clinical - GP Referral
Coaching - Wellbeing or performance - Sport
Coaching - Wellbeing or performance - Personal
Coaching - Wellbeing or performance - Work
Other:
Required
In a few words, please let us know what you would like to work on in your sessions at The Mind Room. [This can help us match you to the right clinician if we do get a cancellation and can open up the waitlist.]
Your answer
Have you been referred to see a particular clinician at The Mind Room? If so, please let us know who (if not, please write N/A):
Your answer
How did you hear about The Mind Room?
*
My workplace EAP (note, we ARE accepting NEW bookings for EAP clients)
I'm a previous Mind Room client
Medical Professional ie. General Practitioner (GP), Psychiatrist
Friend or Family
Social Media (e.g. Facebook, Instagram, Twitter...)
Other:
Required
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