Clients may use this form to update their own contact information, such as an email address, phone number, or postal address. Third parties (for example referrers, legal representatives, or other professionals) may also use this form to notify us of changes to their own contact details where they are involved in a Client’s care or correspondence.

This form is for administrative contact updates only. It is not monitored for clinical matters, appointment changes, requests for information, or urgent issues. Updating contact details via this form does not grant authority to access client information or confirm consent to release information.

Please ensure all details provided are accurate and current. Updates submitted via this form will be applied to the relevant record within a reasonable timeframe. Submission does not require follow-up unless clarification is needed.

Update Contact Details

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 *

Who's contact details need updating? *

Client's

Client's Parent/s

Associated Party of the Client (other than the Parent/s)

Please provide below what complete details you require us to update (e.g., phone number, email, address, Medicare card number, GP details etc) *

0 of 100 max words

Identity Verification Questions

The last 4 digits of the Client's Medicare card number *

The date of the Client's last attended appointment with us *

Invoice Number of the Client's last attended appointment with us *

Consent & Acknowledgement *

I confirm that the contact details provided are accurate and up to date

I understand that this form is for updating contact details only and is not for clinical matters, appointment changes, or requests for information

I understand that submitting this form does not grant authority to access client information or confirm consent to release information

I understand that Vitality Unleashed Psychology will verify this request using existing records and will contact the Client or the requesting party using contact details already held on file before any changes are made.

I consent to Vitality Unleashed Psychology collecting, storing, and updating these contact details for administrative purposes

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