Full Name *

Pronouns:

She/HerHe/HimThey/ThemOther

Date of Birth *

Age **For Clients 18 years and under, we recommend to bring along a support person for your initial appt.

Phone *

Email *

Timezone *TimezoneAustralia / MelbourneAustralia / SydneyAustralia / PerthAustralia / BrisbaneAustralia / AdelaideAustralia / DarwinAustralia / HobartOther - Please Specify in Online EnquiryMust select one of these options.

Preferred Source of Funding: *Preferred Source of Funding:Mental Health Plan (GP referral in place) - ArrangedMental Health Plan (GP referral in place) - Yet to be ArrangedPrivate Fee Paying / Private Health Insurance (Nil GP Referral)AFL Players AssociationNDIS - Self-ManagedNDIS - Plan-ManagedMust indicate your preferred mode of funding. If you have a valid GP referral (valid up to 12 months of issuing date), addressed to Dear Psychologist at Positive Wellbeing Psychology, 64 Glenferrie Road Malvern 3144, please email to info@positivewellbeingpsychology.com.au

Please select the top 3 issue/s you would like help with: *

adjusting to stressful life transitions or loss of directionself-esteem & lacking self-confidencesymptoms of depression or loss of interestsymptoms of anxiety or panicstress management or burnoutperformance anxiety including in competitive sportssleep difficultiespost-natal depression & adjusting to life changesdisordered eating or body dissatisfactiondiagnosed ADHDdiagnosed autism spectrum disordermanaging interpersonal relationships or family dynamicsexploring complex trauma or the impact of early life childhood experiencesalcohol or substance misusemanaging relationship challenges (individual consultations available only)Should you have more to share, you can include this in the text section.

Please indicate when also seeking an assessment:

Assessment - Not ApplicableSuspected Autism Spectrum Disorder (ASD)Suspected Adult Attention Deficit Hyperactivity Disorder (ADHD)If you require an assessment for other concerns, please indicate in your online enquiry.

Your Online Enquiry *0 / 30

Therapy Availability *

Monday 8-4pmMonday 4pm onwardsTuesday 8-4pmTuesday 4pm onwardsWednesday 8-4pmWednesday 4pm onwardsThursday 8-4pmThursday 4pm onwardsFriday 8-4pmFriday 4pm onwardsSaturday 9-4pmNo preferenceOur main priority is to match you with a suitable psychologists, therefore we will do our best to offer one of these timeslots. Should you have no preference, you will likely be offered a time shortly. Attendance notes are available should this assist with flexibility of work/uni commitments.

Upcoming Groups

Processing an Adult ADHD Diagnosis (thoughts, feelings, & letting others in)Making sense of Emotion Dysregulation (Distress/ Anxiety/ Burnout) & PreventionIndicate here should you be interested in being invited to upcoming groups on certain topics (only available to current clients)

How did you hear about us? *

Recommended by GPRecommended by Family or FriendFacebookInstagramAFL Players AssociationNDIS Support CoordinatorGoogle / Search Engine

Do you want to receive monthly newsletters about mental health tips?

Yes please!Not at the moment, thank you!

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