Book Now: New Couples Counselling Client

To make a couples appointment, complete the enquiry form below. Our friendly support team will be in contact within seven days (usually sooner).

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

Make a booking form

    * required

    Please tick below to show that you understand the following:

    These questions help us to match you up to the right team member. Some are optional, and some are required to make a booking.

    Your first name*

    Your surname*

    Your pronouns (e.g. she/he/they)

    Your mobile number*

    Your email*

    How would you like to be contacted?*
    Unfortunately if you don't feel comfortable for us to contact you via either phone or email we are not able to assist you. If the reason you don't feel comfortable with us contacting you via either of these methods is due to family violence, we'd recommend you contact 1800 RESPECT on 1800 737 732 for further assistance.

    Phone callEmailEither, I don't mind

    Your current address*

    Street address

    Suburb

    Postcode

    How did you hear about Inner Melbourne Clinical Psychology?*

    Date of birth (day/month/year)*

    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 pronouns

    Partner's date of birth*

    Partner's phone number*

    Partner's email address*

    Partner's current address*

    What does your partner think is the key reason for coming to couples counselling?*

    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 (please select at least one issue)*

    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 us with some brief information in relation to the following questions.

    What do your fights look like? For example, is there yelling, breaking things, threats, name calling or physical aggression?*

    Do you ever feel unsafe in your relationship?*

    Does your partner ever tell you that they feel unsafe in the relationship?*

    Do you ever feel controlled by your partner?*

    Does your partner ever tell you that they feel controlled by you?*

    Has anyone else ever been concerned about your safety in this relationship?*

    Has anyone else ever been concerned about your partner’s safety in this relationship?*

    Do things ever feel out of control in your relationship?*

    How ready do you feel you and your partner are to work on these challenges?*

    Please provide us with some brief information in relation to the following questions.

    Can you tell us briefly about the concerns you have about abuse or behaviour that may have crossed a line?*

    Do you ever feel unsafe in your relationship?*

    Does your partner ever tell you that they feel unsafe in your relationship?*

    Do you ever feel controlled by your partner?*

    Does your partner ever tell you that they feel controlled by you?*

    Has anyone else ever been concerned about your safety in this relationship?*

    Has anyone else ever been concerned about your partner’s safety in this relationship?*

    Do things ever feel out of control in your relationship?*

    How ready do you feel you and your partner are to work on these challenges?*

    What do you think the key reason for coming to couples counselling is?*

    Are you currently separated or on a break? Please provide some details about this.*

    Are you or is your partner currently thinking about ending your relationship? Please provide some details about this.*

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

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