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 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.

Bita does not offer couples therapy but offers psychoanalytic treatment for individuals addressing relationship issues.* I want to discuss treatment for myself.No

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 PM - Limited AvailabilityNext Available Appointment

Preferred practice location*

What is the purpose of your consultation?*

Medicare rebate usually applies for 6-10 sessions plus a gap fee. After rebates or insurance are used, fees may be adjusted on a sliding scale. Please select your fee category.*

Do you need treatment for a specific disorder / issue? *

Do you have a valid referral?*

How did you hear about me?*

I agree to be contacted by Bita and understand she may request further information to clarify my concerns.

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