Online TeleHealth and Therapy: New Client Registration Page

If you’re a new client please register your details below using the form.

New Client Registration for Online Therapy Services

Tele-Therapy Referral Form

  • Your Details

  • Date Format: MM slash DD slash YYYY
  • Next Of Kin / Emergency Contact

  • If as above please write "As Above" in the first line
  • Primary Diagnosis

  • Occupational Therapy Service Goals

  • Reports- Please Upload It Here

  • Drop files here or
    • Funding Sources for Therapy

    • This field is for validation purposes and should be left unchanged.

    Next Step After Registration: Book Your Appointment Here