Intake form

Full name

Preferred name and pronouns (optional)

Date of birth

Mobile

Will you be located in Australia during your sessions?

State or territory

Service

Preferred language

How will sessions be funded?

GP name and practice (optional)

Emergency contact name

Emergency contact relationship

Emergency contact phone

Parent or guardian name (required if under 16)

Parent or guardian phone (required if under 16)

Parent or guardian email (required if under 16)

What would you like support with? (one or two lines is enough)

Preferred days and times

How did you hear about Oakwise Therapy?

AI-assisted note-taking: with your consent, an AI tool may be used during sessions to help write accurate clinical notes. Zohreh reviews every note before it is saved, and you can change your mind at any time without it affecting your care. See the Privacy Policy.

Do you consent to AI-assisted note-taking?

Yes, I consent No, I do not consent

Terms and Conditions

I have read the Terms and Conditions, including the cancellation policy.

I consent to my information being collected and handled as described in the Privacy Policy.

This form is not monitored for emergencies. If you need urgent help, call Lifeline on 13 11 14, or 000 in an emergency.