Client Name *

First Name

Last Name

Name of Person Completing this Form *

First Name

Last Name

Phone *

(###)

###

####

Client Date of Birth *

MM

DD

YYYY

Are you a Current or Returning Client of Mind Life Clinic? *

Yes

No

Service *

Psychological Assessment

Occupational Therapy Assessment

Deposit *

Mind Life Clinic requires a deposit for all new client appointments. The deposit is due within 48 hours of booking an appointment and can be paid online or over the phone. Please note that we are unable to hold appointments without a deposit for new clients.

I agree

Cancellation Policy *

Mind Life Clinic has a very strict cancellation policy. Any client who “no-shows” or cancels within 3 business days of their assessment appointment will be charged a $300 fee. No further appointments will be permitted until the cancellation fee has been paid.

I agree

Privacy Collection Notice *

When you request an appointment with Mind Life Clinic, we collect your personal information (such as your name, contact details, and reason for seeking support) to help us manage your booking and match you with a suitable clinician. Your information is kept secure and used only for this purpose. We will not share your details with anyone else unless you consent, it is required by law, or it is necessary to protect your safety or the safety of others.

I agree