This form is for new clients who would like to request an initial appointment with one of our psychologists or our dietitian, but who prefer not to book online or need a little extra support with the process.

If you wish to make an enquiry about our services first, please leave this form and complete a service enquiry form instead — this form is for those who have already decided they wish to proceed with booking an initial psychology or dietitian appointment.

You can use this form if

✦You’re booking with our clinic for the first time

✦You’re unsure which service (psychology or dietitian) is the right fit

✦You’d feel more comfortable having our team assist with your initial booking

Submitting this form allows us to

✦Review your request

✦Check availability

✦Contact you to discuss suitable appointment options

If you feel comfortable booking online, that remains the fastest way to secure an appointment. If not, we’re here to help you take that first step.

Request Initial Appointment Booking

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

Client's 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 for the initial consultation? *

In Person at your Gold Coast Clinic

Phone/Video (Telehealth)

Which service/s are you wishing to book an initial consultation for (select all that apply) *

Initial Consultation with Psychologist (Kaitlin Briski)

Initial Consultation with Clinical Psychologist (Ashley Gilmour)

Initial Consultation with Clinical Psychologist for Psychometric Testing (Ashley Gilmour)

Initial Consultation with Dietitian (Tegan Tudor)

Do you have any APPROVED funding or referrals to help with the cost of the 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

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

I understand that completed formal intake and consent forms by the Client or Authorised Person are required before any appointment is confirmed after booking

Today's Date *