Book an Appointment | Bita Psychology

Personal Information

First Name*

Last Name*

Date of birth

Phone number*

Email address*

Street address*

Suburb*

Booking Information

Booking For*

MyselfFamily MemberCoupleChild

Name of the consenting parent*

Does the other parent know you are bringing the child to a treatment session?* YesNo

It is important that both parents or guardians are informed when a child is referred for sessions. If this is not possible or appropriate, such as in cases involving intervention orders, please discuss this with me during your session. Please note: the parent making the booking is responsible for coordinating attendance and payment of fees. Please review the child FAQs for more information.

Have you spoken to your spouse about booking this appointment?* YesNo

Please discuss with your spouse before completing this form. It is important that both of you are in agreement about coming to sessions.

What is the reason you are completing this form on behalf of the family member?* DisabilityLanguage problemsOther

It is important that the individual coming to sessions gives consent and is aware of your referral.

Please describe your issue of concern*

Preferred appointment time (Monday to Thursday)*

Afternoons: 12-4 pmEvenings: 5-10 pmAny next available appointment

Preferred practice location*

Do you have a valid referral?*

How did you hear about me?*

I consent to be contacted by Bita and understand that she may request more information about my personal history. This form serves as consent for engagement with Bita Psychology and will be stored in my patient file. If no appointment is booked, the referral information will be discarded within 14 days. Yes

Bookings with Bita
Psychology

Please use this form to book an appointment.

Personal Information

Booking Information

Bookings with Bita Psychology

Please use this form to book an appointment.

Personal Information

Booking Information

Bookings with Bita
Psychology