This form is for existing clients who would like to request a follow-up or ongoing appointment with their psychologist or dietitian, but who prefer not to book online or need assistance with scheduling.

Use this form if

✦You are already a client of our clinic

✦You are seeking a subsequent appointment (not your first visit)

✦You would like support with appointment availability, timing, or continuity of care

Submitting this form allows our team to

✦Review your request

✦Check clinician availability

✦Contact you via SMS or email to discuss suitable appointment options

Please note

✦This form is not for urgent or crisis support

✦Appointment availability cannot be guaranteed

✦Requests are reviewed during business hours and may take several days to process

If you are comfortable booking online, that remains the fastest way to secure an appointment. If not, we’re happy to help you continue your care in a way that feels manageable.

Request Subsequent 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

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 for the subsequent consultation? *

In Person at your Gold Coast Clinic

Phone/Video (Telehealth)

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

Subsequent Consultation with Psychologist (Kaitlin Briski)

Subsequent Consultation with Clinical Psychologist (Ashley Gilmour)

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

Subsequent Consultation with Dietitian (Tegan Tudor)

Has your referral or funding changed since your last appointment with us? *

Yes (Please specify below)

Changes to Referral or Funding

Which APPROVED funding or referrals do you have to use for this consultation/s? (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)

Please submit relevant funding approval (where applicable)

Maximum file size: 10MB

How soon do you require this next appointment? * How soon do you require this next 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

Today's Date *

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

Feel more like yourself.

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Get in touch

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

Book Online

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

Request a Subsequent Appointment

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