Client's Name *

First Name

Last Name

Telehealth

I am wanting in-person appointments ONLY

I am wanting online appointments ONLY

I'm interested in either/both formats of support

If you are enquiring as a guardian on behalf of an adult client please provide enquirer's name:

First Name

Last Name

Phone number *

(###)

###

####

Client's Date of Birth *

MM

DD

YYYY

Client's Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Will you be accessing With Youn services under a?

Mental Health Care Plan

NDIS

Private

Other

If under NDIS, how is this managed?

Self-Managed

Plan-Managed

NA

Please tell us which type of allied health / therapy services the participant has previously accessed. *

Occupational Therapy

Speech Pathology

Psychology

Physiotherapy

None of the above

Have not accessed

How is the NDIS plan managed (if applicable)?

Self-managed

Plan-managed

Will you be accessing With You services under a Mental Health Care Plan? *

Yes

No

ATT *

Animal Assisted Therapy - Canine

I understand that some practitioners at the practice have canines as part of their therapy process, and that it is likely I may encounter them. I can let admin know if there is a concern.

Payment *

Please note, in order to secure your initial appointment, upfront payment is required, unless NDIS Plan Managed. In the event the appointment is cancelled, and this is outside the cancellation period, third party transaction fees are deducted from the total fee refunded.

I understand

Expression of Interest

I understand that I will be placed on an expression of interest list and be sent an email in the coming weeks. We will be in touch when a position becomes available.

Yes, I understand.

How did you hear about us? *

Social Media

Website

Word of Mouth

Conference / Expo

Event

Other