Ready to get started? Complete the form below and our team will be in touch to arrange your appointment — for psychology or dietetics, in person in Bundall or via secure telehealth Australia-wide.

You don’t need a referral to begin, though we warmly welcome one if you’d like to access Medicare rebates. Tell us when you’re available and what you’re seeking support with, and we’ll match you with the right clinician and a time that suits.

Complete the request form ↓ Prefer to talk? 0474 919 759

Takes just a few minutes · No referral needed to start

Three simple steps

How it works

Complete the form

Tell us your availability, what you’d like help with, and any referral or funding you have. It takes just a few minutes.

We get in touch

Our intake team reviews your request and gets in touch to confirm the right clinician, time and any details.

Your first appointment

Meet your clinician — in person at our Bundall clinic, or via secure telehealth wherever you are.

If you need help now

Please note: this form is not monitored around the clock and is not for emergencies. If you are in crisis or worried about your immediate safety, please call 000, or Lifeline on 13 11 14 (24/7). You can also text Lifeline on 0477 13 11 14.

Call 000 Lifeline 13 11 14

Secure & confidential

Request Appointment Form

Please complete this form to request a psychology or dietetics appointment. Tell us your availability and what you’re looking for, and our team will be in touch to confirm your booking. No referral is needed to start.

Request an Appointment

Who is completing the form? *

I am the Client

I am a Parent / Legal Guardian completing this on behalf of a client

I am a Third Party (e.g., GP, psychiatrist, school, solicitor, insurer, employer)

Other (please specify)Other (please specify)

Your Details

Your Name *

Your Name

First Name

Last Name

Your Phone Number *

Your Email *

Your relationship to the client *

Your Organisation

Client's Details

Client's Name *

Client's Name

First Name

Last Name

Client's Phone Number *

Client's Email Address *

Client's Age *

Client's Town/City *

What consultation method do you prefer? *

In Person at your Gold Coast Clinic

Phone/Video (Telehealth)

What is the purpose of the psychological assessment/diagnosis process? *

For my own personal information and/or to guide Psychological Therapy I may need

NDIS Application

Centrelink Disability Support Pension (DSP) Application

Legal or Forensic Purposes (e.g., compensation)

Other Compensation Claim

Other Reason (Please specify)Other Reason (Please specify)

What mental health concerns have you been experiencing? (tick all that apply) *

ADHD

Addiction/s

Anger / Aggression

Anxiety

Autism / ASD

Bipolar Disorder

Cognitive Issues

Depression

Eating Disorder or Feeding Disorder

Life purpose / direction issues

OCD

Grief / Loss

High Stress

Intellectual Impairment

Personality Disorder

PTSD / Trauma

Psychosis (e.g., Schizophrenia)

Relationship / Family issues

Suicide or Self-Harm

Workplace issues

Other (Please Specify)Other (Please Specify)

Please tell us more information about what struggles or concerns you have been experiencing, and what you would like to get some help with from psychological consultations/sessions? *

0 of 500 max words

Do you have any APPROVED funding or referrals to help with the cost of the psychological consultations? (Please note, we do not accept DVA) *

No (Private Paying only)

Mental Health Care Plan (MHCP) referral

Eating Disorder Management Plan (EDMP) referral

Chronic Disease Management Plan (CDMP) referral for 'Psychology'

Worker's Compensation claim (e.g., WorkCover Qld or other)

Insurance Company (e.g., motor vehicle)

Legal compensation

NDIS

Victim's Assist (Victims of Crime)

Sporting Club/Association (e.g., NRL, AFL, AFLPA, Swimming Australia etc)

Other (Please Specify)Other (Please Specify)

How soon do you require your first appointment? * How soon do you require your first appointment?

How did you hear about us? * How did you hear about us?

Please specify what Days and Times of those days you are available for your first appointment (or when you are NOT available, if that is easier). Our consultation times vary depending on what day Mon-Fri *

0 of 100 max words

What is your preferred method of contact from us? *

SMS

Consent & Acknowledgement *

I understand that this form is an enquiry only and does not guarantee appointment availability

I understand that this form is not monitored continuously and is not for urgent or crisis support

consent to Vitality Unleashed Psychology contacting me via my contact details in relation to this enquiry

I understand that formal intake and consent forms are required before any appointment is confirmed after booking

Today's Date *

Who is your preferred practitioner?

Ashley Gilmour (Principal Clinical Psychologist)

Kaitlin Briski (Psychologist)

Tegan Tudor (Accredited Practising Dietitian)

No preference

Already a client?

If you’re an existing client and ready to book, you can also book online any time.

Book online 24/7 →

Not sure where to start?

That’s completely fine — tell us what’s going on in the form above and we’ll help you work out the right first step. Or give our friendly team a call.

Text us on 0474 919 759 Read our FAQs

In person in Bundall, Gold Coast · Telehealth Australia-wide

Warm, evidence-based psychology and dietetics on the Gold Coast — in person and via telehealth.

Feel more like yourself.

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Client Resources

FAQs Submit a Request Fees & Rebates Medicare Rebates Cancellation Policy For Doctors Blog

Get in touch

Upton Professional Suites
Level 1, 105 Upton Street
Bundall QLD 4217, Gold Coast
contact@vitalityunleashed.com.au
(07) 5574 3888 (answered by SophiieAI, our digital assistant)
Fax (07) 5676 6522

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Vitality Unleashed Psychology acknowledges the Traditional Custodians of the land on which we work, and pays respect to Elders past and present.

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