Appointment Request Form – Birchtree Centre of Excellence

Waiting list

Name *

First

Last

Phone *

Email *

Referred by *

Your General Practice *

Your postcode *

Please select your age *

Have you had therapy before? *

Do you want to see a specific therapist? *

Would you prefer to see a female or male therapist? *

Do you have a history of:

Areas of concern: please say a little about what you would like help with *

Which days and times suit you best, on an ongoing basis? *

Do you have a Mental Health Care Plan *

Fee Information

Is there any other important information you feel we should know?

Treatment for Trauma, Addictions and Eating Disorders