Psychologist Request Form

Consult with a Psychologist

Connect with a qualified psychologist online
What do you wish to speak to your Psychologist about today?

Please note that for every consultation you will only be able to discuss a single issue.
What would you like to talk about today?*

0/0
Contact Details

Please double check the information is accurate to ensure a seamless process.
Email*
example@example.com
Mobile number*
Confirm mobile number*
The mobile number entries do not match. Please check and try again.
Patient Information

Please ensure that you input the details of the person requiring the consultation.
Patient full name*

First NameLast Name
Date of birth*

DayMonthYear
Date
Gender*

MALEFEMALE
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Please input a valid state code eg. NSW, QLD, VIC, TAS, WA, SA, NT, or ACT

Select your session

Psychology Session - 50 minutesDiscuss a single issue with a health practitioner. Your request will be added to the queue.

$99.00AUD

Total

$0.00AUD

By clicking submit you agree that: (a) you are not experiencing a medical emergency, serious medical condition, or any condition which requires immediate or urgent treatment; (b) your personal information (including health information) will be shared with all Partner Practitioners on the Updoc platform to enable continuity of care; and (c) that all the information you have entered and will provide to Partner Practitioners is true and correct. You also agree to our Terms & Conditions and Privacy Policy.
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Consult with a Psychologist