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(07) 3801 1772
(Loganholme) or
(07) 3823 2230
(Cleveland)
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Expression of Interest – Groups
Expression of Interest Registration Form
Details of Young Person
Name & Surname of Parent/Carer
*
Name & Surname of Young Person
*
Best Contact Number of Parent/Carer
*
Email
*
Age of Young Person
*
Gender
*
Male
Female
Post Code
Please list the post code of your home address.
Group Details
Group You Would Like To Register For
*
Cool Connections (ages 9-14)
Resilient Minds (ages 14-18)
Social Communication & Conflict Management (ages 9-14)
Previous Counselling with The Psych Professionals
Is your child/teenager a current or previous client of our practice?
Current
Previous
No
How did you hear about the Groups?
My Psych Professionals Psychologist
Notice in The Psych Professionals Waiting Room
My GP
Facebook
Google
Family or Friends
Other
Previous Counselling
Has your child/teenager attended counselling with a Psychologist during the last 6 months?
Yes
No
Diagnosis, Concerns, Challenging Behaviour or Presenting Problem:
If your child/teenager has received a mental health diagnosis from either your GP/Paediatrician/Psychiatrist/Psychologist, please specific such.
Health Care Card
*
Do you have a current Health Care Card?
Yes
No
Questions or Comments
If you have any additional Questions for us or would like to make any Comments not covered by this form, please list such.
Verification
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