Couples therapy enquiry form

Once you have completed the form below, our friendly Support Team will be in touch within two business days (usually sooner) to let you know if we have a therapist who is the right fit for you.

If you have any trouble using this form, please get in touch.

Before you complete this form, please note that:

  • IMCP does not provide crisis services or immediate appointments, court reports, one-off assessments or services via third parties. For support during a crisis, please click here.
  • If the information you provide indicates that a child may be at risk, we’re legally required to make a report to child protection, even when someone is seeking help in good faith. We take this responsibility seriously and handle all concerns with care and respect.
  • The questions in this form help us to match you up to the right team member. Some are optional and some are required to make a booking.

    * required

    Your details

    Your first name*

    Your surname*

    Your preferred name

    Pronouns you would like us to use (optional)
    For example she/her, he/him, they/them

    Your mobile number*

    Your email*

    Your current address*

    Street address

    Suburb

    Postcode

    How did you hear about Inner Melbourne Clinical Psychology?*

    Date of birth (day/month/year)*

    Your partner's details

    To book you in, we will need the following details about your partner:

    Please be aware that if you do book an appointment with us, we will contact both yourself and your partner with appointment details and information.

    Partner's full name*

    Partner's preferred name

    Pronouns your partner would like us to use (optional)
    For example she/her, he/him, they/them

    Partner's date of birth*

    Partner's phone number*

    Partner's email address*

    Partner's current address*

    All of our counsellors are LGBTQIA+ affirmative, but if you would like to work with someone who also has specific training and experience in working with these communities, please tick this box and we'll ensure you're matched with someone who is suitable.
    Yes, I would like to be matched with a counsellor trained and experienced with LGBTQIA+ communities.

    Please tick the issue/s you would like help with*

    Select at least one issue in total across all headings (maximum of five)

    Connection, trust and communication

    Conflict and relationship patterns

    Intimacy and sexuality

    Parenting, family and life pressures

    Individual wellbeing affecting the relationship

    Identity, values and differences

    What does your partner think is the key reason for coming to couples counselling?* (300 characters max)

    What do you think the key reason for coming to couples counselling is?* (300 characters max)

    Are you currently separated, on a break or thinking about ending your relationship?*

    Please be aware, if you or your partner are involved with court proceedings or engaged with a lawyer, or if either of you think you may be in the future, we will not be able to provide therapy in this case.

    Please provide some brief details about the separation or break.* (300 characters max)

    Please let us know if there is any other information that you think would be helpful for us to know when matching you up with one of our couples counsellors. (500 characters max)

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