If you would like to request an appointment at Mind Body Well please complete and submit the form below. We will respond within 24 hours of receiving your request (week-days).

For details about our approach: see our TREATMENT PHILOSOPHY

For details about our therapies: see PSYCHOLOGICAL THERAPY, DIETETIC THERAPY and EATING DISORDER THERAPY

For details about care plans and referrals: see our REFERRALS information, or CONTACT US

For information about our fees and Medicare claiming: see OUR FEES

New Client Appointment Request Form

Please complete all details marked as required, and other details as relevant. Your form will be forwarded to us after you press SUBMIT at the end, and you will be directed to a page which says ‘Thank you for making contact’. If you have any difficulties with the form, please contact our office directly.

PLEASE NOTE: We are not a Bulk Billing service (out of pocket fees apply), and we are currently providing therapy for adult clients only (over 18).

Name

First Name

Last Name

Email Address

Mobile Phone number

Date of Birth (we are currently seeing adult clients over 18yrs)

If you are completing this form on behalf of someone else please provide your name, relationship to the person, and your contact details

How did you find out about Mind Body Well?

Have you been referred to our practice by another health professional? If so, please provide their name

Please indicate your availability for appointments

Please note, appointments outside business hours are VERY limited, and will require a significantly longer waiting period

Weekday business hours

Weekday after hours

Please tick here if you have a Health Care Card or Pension Concession Card, and may be eligible for concession rates

We have a very limited number of concession appointments available, which may necessitate a longer waiting period. Concessions are not available for after hours appointments. LEAVE BLANK if n/a

Yes

Please select whether you prefer In-person or Telehealth (online via video) therapy?

Is your request to see a specific Therapist?

If so, please select (leave blank if n/a) . Please note, we may not be able to meet this request due to therapists current case loads

What type of therapy are you seeking?

Please note: our Psychologists do not provide secondary therapy for people who are currently seeing another Psychologist

Please briefly outline your reasons for seeking therapy, and/or your goals for therapy. Please provide enough information to assist us to allocate you to an appropriate therapist

Are you seeking therapy for an eating disorder? IF NOT - please ignore this question. IF YES - please read and tick to indicate that you meet our service criteria and believe we are an appropriate service for you

Yes, I am seeking therapy for an eating disorder and I meet the following criteria - over 18 years of age, having regular medical reviews, and I have a BMI over 16

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