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
Name
First Last
Date of Birth*
Date Format: MM slash DD slash YYYY
Sex
Gender Identity
Do You Identify As
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone*
Email*
Enter Email Confirm Email
Consent
I agree to the privacy policy.
I agree to Occupational Therapy Brisbane a service of Get Healthcare Direct PTY LTD (GHD) to store my information in order to support clinical and practice related communication and activities such as newsletters, podcast, training, education for example. GHD agrees not to release your information to any other parties unless with your express permission.
Next Of Kin / Emergency Contact
Name
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
If as above please write "As Above" in the first line
Primary Diagnosis
What are your primary medical diagnoses?
Occupational Therapy Service Goals
How Can We Help You?*
- I've a neurological condition and what to live better and independently
- I'm concerned about my memory and want to get it checked
- I need a workplace assessment
- I want to modify my home so I am safe and independent
- I'm looking for a therapist to help with my Rehabilitation
- I'm a carer needing a consultation for my client or loved one
- I'm an NDIS participant
- I've a medico legal referral
Reports- Please Upload It Here
Upload Your Relevant Reports
Drop files here or
Funding Sources for Therapy
Who will be paying for services?*
Comments
This field is for validation purposes and should be left unchanged.