Client Name *

First Name

Last Name

Name of Person Completing this Form

First Name

Last Name

Phone *

(###)

###

####

Client Date of Birth *

MM

DD

YYYY

Drivers Licence Expiry Date

MM

DD

YYYY

Address on Drivers Licence

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Next of Kin *

First Name

Last Name

Next of Kin Phone *

(###)

###

####

Are you a current or returning client of Mind Life Clinic? *

Yes

No

Payment *

Mind Life Clinic requires payment in full prior to the Clinical Assessment. An invoice will be forwarded to your email address once an appointment is booked.

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 appointment will be charged a $300 fee. No further appointments will be permitted until the cancellation fee has been paid.

I agree

Additional Fees *

The use of a disability-trained Driving Instructor and Test Vehicle is a separate business to Mind Life Clinic and a requirement of the OT Driving Assessment. This attracts an additional fee of approximately $440.

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