Book Telephone Session

Help is as close as the telephone

Yes, I want to schedule a telephone session

Please note that all fields followed by an asterisk must be filled in.

First Name*
First Name*

Last Name*
Last Name*

E-mail Address*
E-mail Address*

Street Address*
Street Address*

City*
City*

State/Prov*
State/Prov*

Zip/Postal Code*
Zip/Postal Code*

Country*
Country*

Home Phone*
Home Phone*

Business Phone

Creditcard*
Creditcard*

	A. Bankcard
	B. Mastercard
	C. Visa

Cardnumber*
Cardnumber*

Expiry date*
Expiry date*

Name as shown on card*
Name as shown on card*

Number of sessions required (recommend 3-6) at $AU227 each (note will not be billed until appointments are confirmed)*
Number of sessions required (recommend 3-6) at $AU227 each (note will not be billed until appointments are confirmed)*

Total amount*
Total amount*

A full client intake/history form will be privately emailed on receipt of the application and that this document is viewed only by the Clinical Services Director and/or the assigned therapist.

Disclaimer