Western Psychological Services
All information provided to us will remain confidential.
Which phone number can we contact you on?
PLEASE NOTE: We will not identify ourselves when calling apart from giving our name.
Emergency Contact Details
Only in emergency
List any languages other than English that are spoken by you and your family:
Are you attending under an employee assistence program?
Billing Department Code:
Name of your Doctor:
Workcover / VOCAT
Transport Accident Commission (TAC) Claimants
Number of dependent children living with you (if applicable):
If yes, when?
How long had you been attending counselling?
Could you briefly describe what has brought you to counselling and what you are hoping to achieve from your sessions?
The following information will be discussed with your psychologist during your first appointment.
By submitting this form I agree that I have been informed of the above practice policies.