New Clients - Constellation Therapy

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To enquire about seeing one of our practitioners, please fill out this form.

For more information on our practitioners, see ‘Our People’ (opens in new tab).

Have a question? Contact us at [email protected] or (02) 8880 9913.

Are you filling out this form in regards to yourself, or someone else? *

Myself
My child
Someone else

What is your relationship to the client? *

Your Details (Contact Person)

Name *

First

Last

Phone *

Email *

Your Details

Client Details

Legal Name *

First

Last

We use your legal name to process Medicare claims, invoicing, and for other similar purposes

Preferred Name

Leave blank if same as legal name. We will always use your preferred name when contacting you.

Date of Birth *

Phone *

Email *

Gender

Man
Woman
Non-binary
Different identity

Please specify

Preferred Pronouns

He/Him
She/Her
They/Them
Different pronouns

Please specify

What are the main issues you are seeking help with? How have these issues been impacting life? *

The more detail you provide, the better able we will be to ensure that you see the practitioner who is right for you and who has the appropriate experience to provide you with support. Your information will be stored securely, and held in strict confidence.

Are you looking for support around issues of gender or sexuality?

Yes
No
Prefer not to say

We work with people from all walks of life looking for support on a wide range of issues – we ask this question only so that we can get a better understanding of the type of support you’re looking for.

Are you currently involved in any relevant legal matters before a court? *

Please describe the relevant legal matters you are involved in *

Which practitioners would you consider seeing? *

Anyone
Amy Harper
Roula Poretsanos
Sekneh Beckett
Jessica Hazzard-White
Clara Morchio
Fiona Cobain

Tick any number of boxes

Is there a specific practitioner who is your first preference? *

No preference
Amy Harper
Roula Poretsanos
Sekneh Beckett
Jessica Hazzard-White
Clara Morchio
Fiona Cobain

Referral

A referral is not required. However, with a valid referral letter from a doctor, you are entitled to a Medicare rebate to help cover the costs of psychology appointments. If you don’t have one, you may wish to consult with your GP after completing this form, before your first appointment. See our FAQs page for more information about referrals.

Do you have a referral letter written by a doctor? *

Yes
No
No, but I intend to get one

Do you intend to use NDIS funding?

Availability

At present, appointments are only available on weekdays.

What days of the week are you available for appointments? *

Monday
Tuesday
Wednesday
Thursday
Friday

Tick any number of boxes

What times of day are you available for appointments on a typical day? *

Before 10am
10 am – 1 pm
1 pm – 4 pm
4 pm – 6 pm
6 pm or later

Tick any number of boxes

Do you have a preference for in-person or telehealth appointments? *

Either is fine
Preference for in-person
Preference for telehealth

Any other comments?

How did you hear about us?

Google
Referred by Doctor
Word of Mouth
Other

Please specify