Bookings

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 session?* YesNo

It's important that both parents or guardians are informed when a child is referred for therapy. If this isn't possible — such as in cases involving intervention orders — please raise this during your session. The parent making the booking is responsible for coordinating attendance and payment. Bita meets with one or both parents first, as appropriate, to understand the child's context and family environment.

We do not offer couples therapy. Individual therapy is available to those wanting to talk and work through relationship issues. * I want to discuss therapy for myself. Please select 'Myself' from the options above.

Bita does not offer joint sessions for shared relationship concerns, as individual issues require privacy for proper exploration. She offers one-on-one sessions for individuals to discuss their relationship, while partners can seek separate therapists for their own concerns.

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 *

Day: 11 AM - 4 PMEvening: 5 PM - 9:30 PMNext Available Appointment

Preferred practice location*

I'm Seeking: *

Rebate applies for 6-10 sessions. Fees can be adjusted to make therapy affordable. Please select your fee category.*

Do you have a valid referral?*

How did you hear about me?*

I agree to be contacted, and understand further questions may be asked to clarify my concerns.

Request an Appointment

Bookings

Personal Information

Booking Information