Private Client intake form

Referrer/Parent Details

First Name

Last Name

Phone

Email

Address

Postal code

Reason for referral

Client's details

First name

Family name

Phone

Email

Gender identity

Date of birth

Address

Payer details
(responsible for payment)

First Name

Last Name

Phone

Email

Address

Postal code

preferred language

Persian/Farsi

English

Client's disability (if applicable)

Behavioural risk assessment

Please select the required service

Counselling (trauma/family therapy)

Clinical Art therapy

Equine Assisted Therapy

Trauma Informed Self-defence (Martial Arts)

Home visit ($96.99 flat rate)

Clinic based therapy

Virtual appointment

Clinical Play Therapy

Student Internship Program

Occupational risk assessment

Additional information

Your Signature

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Art Therapy, Play Therapy and Music Therapy in Melbourne | Wonderful Mind | Areas We Serve | Level 1, 1 Laurimar Blvd, Doreen VIC 3754

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Private Client intake form

Client's details

Payer details (responsible for payment)

Payer details
(responsible for payment)