Therapy Contact Form

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Email *

Today's Date *

YYYY

Name *

Date of birth *

YYYY

Email address *

Please could you briefly describe what you are struggling with? *

Have you had therapy previously? *

Yes

If so, could you briefly describe what therapy you have tried before and how you found this?

Are you currently seeing another mental health team/mental health professional? *

Are you looking for face to face or online therapy? *

Face to face - Kings Cross (Monday morning 9am-2pm)

Face to face - Kings Cross (Wednesday morning (9am-2pm)

Online (Tuesday/Thursday morning)

Other:

Required

Are you looking to self fund therapy or fund via insurance? *

Self Funding

BUPA

How did you hear about Beyond the Clinic Room? *

Google Search

Recommendation

Social Media

Other:

Your Privacy

I understand that my details will only be used by Beyond the Clinic Room to deliver professional services and will not be shared with anyone else.

Required

Thank you very much for filling out this form. We will be in contact with you as soon as possible.

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