New Client Form

Getting Started

Welcome! This form helps me understand your needs and how I can best support you. It should take about 10-15 minutes to complete.All information is kept strictly confidential.

New Client Intake Form

Personal Information

First name

Last name

Birthday

Day

Month

Year

Multi-line address

Country/Region

Address

City

Zip / Postal code

Phone

Is it safe to call, message and/or leave a voicemail?

How would you like us to contact you?

Emergency Contact

Name & Relationship

Phone

Client Information

What are you hoping to address in therapy?

What are your goals for therapy?

Have you had therapy or counselling before?

If yes, please provide details:

Have you heard of or tried EMDR therapy before?

If yes, please provide details:

Are you coming here specifically for EMDR therapy?

Have you ever had any mental health diagnoses such as Anxiety, Depression, or PTSD?

Are you currently seeing any other health professionals?

Are you currently taking any medications?

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

If you're in crisis right now, please contact Lifeline 13 11 14, Beyond Blue 1300 22 4636, or present to your nearest emergency department. Go With That Therapy does not provide crisis support.

Appointment Preferences

Please tell us about your preferred appointment times. Available options include:

Monday (Evenings)
Tuesday (9:00am-3:00pm)
Wednesday (Evenings)
Thursday (Evenings)
Friday (9:00am-5:00pm)

Please note that appointment preferences will be considered; however, availability cannot be guaranteed.

How soon would you like to start?

Medicare & Payment

Do you have any type of funding or are you planning to use a Mental Health Treatment Plan? Please provide details below.

Please note that all sessions are paid through Halaxy, our secure practice management system, on the date of service provided.

Additional information

Is there anything else about your physical or mental health that would be important for me to know prior to engaging in therapy?

Where did you hear about us?

Before you submit

Cancellation policy

I understand that life happens. If you need to reschedule or cancel, please provide at least 48 hours (2 business days) notice.

Cancellations with less than 48 hours notice: 50% session fee
Same-day cancellations or missed sessions: Full session fee

Please Note

Submitting this form is a request for therapy services, not a confirmed booking. I'll be in touch within one business day to confirm availability and next steps.

I have read and agree to the cancellation policy and understand that submitting this form does not guarantee a booking

Thank you for reaching out. I'll respond within one business day.

Crisis SupportGo With That Therapy does not provide a crisis response service. If you're in immediate crisis or at risk of harm, please contact:

Lifeline: 13 11 14 (24/7)
Beyond Blue: 1300 22 4636
Emergency services: 000