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Please complete an intake form below if you are a new client wanting to book in with Bianca.

For more information about rebates and appointment times, please visit the FAQs tab.

Notice: please be aware that Bianca will be unavailable from 10 October 2025 until 7 November 2025. Any new enquiries submitted during this time period will receive a response after 7 November 2025. We appreciate your patience!

Child/Adolescent Intake Form

Please complete this form if you are enquiring about therapy for your child. If you are an adult enquiring about therapy for yourself, please scroll down to the Adult Intake Form.

Parent/Guardian First Name*

Parent/Guardian Last Name*

Email*

Phone (please ensure area code is included)*

Child's full name and age*

Parental/Guardian Relationship Status *

Couple

Single Parent

Separated

Divorced

Other (please specify in summary section below)

Do all required parental/guardian parties consent to the child attending sessions? (If a custody agreement is in place, consent from both parents is required for sessions to proceed.)*

Yes

Please give a brief summary of what you are seeking support for:*

Do you have, or plan to access, any funding or rebates for sessions?*

Medicare rebate (GP Mental Health Care Plan)

NDIS (self-managed)

Private health insurance

Adult Intake Form

First name*

Last name*

Date of Birth*

Day

Month

Year

Email*

Phone (please ensure area code is included)*

Please give a brief summary of what you are seeking support for*

Do you have, or plan to access, any funding or rebates for sessions?*

Medicare rebate (GP Mental Health Care Plan)

NDIS (self-managed only)

Private health insurance

We acknowledge the Traditional Custodians of Country throughout Australia and their continuing connection to land, waters and community. We pay our respects to Elders past, present, and emerging, and extend that respect to all Aboriginal and Torres Strait Islander peoples today.

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