At Person Centred Psychology & Allied Health we understand the importance of matching you with the most appropriate clinician to ensure you have a positive experience of therapy.

To help us establish who on our team might be the best fit for you, please complete the form below.

Once we have received your form, we will contact you within 2 business days to discuss next steps.

Please note: Person Centred Psychology & Allied Health is not an emergency service and is unable to provide urgent care.

If you are experiencing an emergency, phone 000, Lifeline on 13 11 14 or go to your nearest emergency room.

Full Name

First Name

Last Name

Date of Birth

Contact Number

Email

If you are completing this form on behalf of someone else, please list your full name, relationship and contact number

Referral Source

Appointment Type

Psychological Services

Dietetics Services

Both Psychology and Dietetics Services

Please provide a brief summary on the reason for your appointment request:

Appointment Attendance

In clinic

Telehealth

Either option

Thank you. We will be in touch within 2 business days to discuss next steps.

Mental Health Intake Form