Register

Child Registration

Please note that for a child, both parents/legal guardians must provide consent. If there are extenuating circumstances, please contact us to discuss.

Parent/Guardian 1: Full Name

Parent/Guardian 1: Email Address

Parent/Guardian 1: Phone Number

Parent/Guardian 1: Address

Parent/Guardian 1: Has parental responsibility for child?

Parent/Guardian 1: Please note any relevant court orders

Parent/Guardian 2: Full Name

Parent/Guardian 2: Email Address

Parent/Guardian 2: Phone Number

Parent/Guardian 2: Address

Parent/Guardian 2: Has parental responsibility for child?

Parent/Guardian 2: Please note any relevant court orders

Child's Name

Child's Date of Birth

Child's Gender

Other genderIf your child's gender is not listed above, please let us know your preference

Child's Preferred Pronouns

Other pronounIf your child's pronouns are not listed above, please let us know your preference

Please let us know the general reason you are contacting us today, or the reason for your referral

Is your child a current or returning client of Bellarine Psychology?

Does your child have any family or friends attending Bellarine Psychology?

Please let us know if you have a preferred clinician?

Is your child currently involved with any legal matters?Please note that Bellarine Psychology does not provide reports or advice for legal matters.

Would you prefer appointments via Telehealth?

Does your child have a referral?Please ask your child's GP to send the referral to us at reception@bellarine-psychology.com.au

How did you hear about us?

Will you be utilising approved NDIS funding?