Request Appointment Form

Please complete this form to request either a Psychology and/or Dietitian appointment with our clinic.

"Take the next step to returning to wellness!"

Name

Email

Phone

Days available for appointment

Preferred appointment time

7am-11am
11am-2pm
4pm-7pm

Available day

Preferred time

Do you require an appointment within the next 24 hours?

Yes
No

Are you currently or have you recently been experiencing thoughts of self-harm or suicide?

Yes
No
I'd rather not say

Whilst we will attempt to contact you on the same business day about your enquiry, this question just lets us know how urgent we need to get back to you about your enquiry and how soon you might need an appointment with one of our practitioners.

What are your current concerns? tick all that apply

Dietitian clients: if you have any mental health concerns, tick all that apply. If you have no concerns, leave this section blank.

Who is your preferred Psychologist?

Dietitian Clients:

What are your current concerns? tick all that apply*

Acute or Chronic Disease Management (eg heart issues, cancers, thyroid issues, diabetes)
Eating Disorders or Disordered Eating (eg Anorexia or Bulimia Nervosa, Binge Eating Disorder)
Feeding Disorders (eg Avoidant Restrictive Food Intake Disorder, PICA)
Other

Do you have a GP referral or have been referred by your Sporting Club or Workplace?

You do not need a referral to book an appointment with our clinic. However, if you do have one, or if you are coming from your sporting club or workplace please specify.

Referrals:

Doctor who referred you? Include Medical Centre if you have this

Anything else we should know?