This form must only be completed with the informed consent of the client being referred for psychological consultation.
It is advised that all parties be familiar with The Humanitarian’s Privacy and Service Terms & Conditions before proceeding.
View Charter of Service
View Terms and Conditions of Service
View Terms and Conditions of Website
Please use this form for requesting consultation for the purpose of:
Complete securely* online
* information provided online is SSL encrypted in transmission.
(Note that this information will be openly discussed in the session)
(Note that if feedback is required, this will be shared with the attendee prior to disclosure)
- PRICES ARE QUOTED IN AUSTRALIAN DOLLARS
Note that 10% GST will be charged to organizations requesting and paying for a psychological service on behalf of the attendee.
A 50% cancellation fee will be applied for appointments not attended or cancelled within 24 hours of service.
By submitting this form, you are authorizing the service to proceed with an understanding of the Charter of Service, Privacy Policies and Terms and Conditions under which The Humanitarian operates.
Both the attendee and the person organizing the appointment will be emailed with appointment options times as soon as possible and within 3 working days of receiving this form.
In the event of a technical hitch, if you do not receive contact from The Humanitarian to discuss or to arrange a convenient appointment time within 3 days, please contact psychologist, Amanda Allan directly by email: firstname.lastname@example.org or phone +61 409 007 629.
Click to submit form if you have read the Charter of Service, Privacy Policies and Terms and Conditions by which this service is conducted.
Any queries, please email email@example.com