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Counselling Services Registration of Interest

If you have any questions, please let us know at hello@chatwell.com.au or (08) 8102 0118.

What is your child's full name?

What is your child's date of birth?

What is your child's date of birth?
Day
Month
Year

What is the parent/caregivers full name?

What is your email address?

What is your best contact number?

Please provide a short description of why you or your child require counselling services?

Do you or your child have a diagnosed communication disorder or a disability?

Has your child had a autism assessment previously
Yes
No

Have you or your child seen a counsellor or psychologist before?

Previous counsellor Assessment?
Yes
No

What would you like to gain from counselling?

How will the appointments be funded?

How are the NDIS funds managed?

Which of our clinics are you interested in attending?

Which clinic are you interested in attending

What is your therapy preference?

Therapy Preference
Face-to-face only
Open to tele-health

Is there any other information you would like to share?

How did you hear about Chat Well Allied Health?

How did you hear about Chat Well Allied Health?
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