Name *

First Name

Last Name

Occasionally we have last-minute cancellations (within a 24-48 hour time frame). Please note that they are generally during the day between 9am - 5pm. *

Please note that they are generally during the day between 9am - 5pm. Please let us know if you would like to be offered these late-notice appointments.

Yes I have good flexibility

No I will need more notice

Please specify if you require support for an adolescent or an adult *

Adolescent (16+)

Adult

Please specify the type of therapy required *

Individual therapy

Couples therapy

Pleas specify if you are wanting to see a Covid-conscious therapist or therapist or support for Long Covid

Yes

Current Gp Referral & Mental Health Care Plan

Yes

No

I understand that Fremantle Clinical Psychology and Counselling is a private billing practice and that the practice fees (and rebates) will apply as outlined in the Frequently Asked Questions on our website. Please note: We do not currently have any bulk-billed appointments available and a gap payment will apply for all appointments *

Yes