Request Therapy Form

If you would like to take charge of your emotions or improve your ability to build, develop and maintain healthy relationship, please complete the form below and I will get back to you to find an initial session time.

TherapyRequestForm

Your Name

First Name

Last Name

Your Email

Your mobile number

The reason(s) you are seeking therapy

Payment Tier (45 minute session)

Standard (120AUD)

Reduced (60AUD)

POSTCODE or timezone

Permission to contact/store information

I grant Michael Wallis permission to contact me via the methods listed above and have read and agree to the therapy privacy policy

Therapy Preference

Telehealth

Public Space Counselling

Alternative (to be negotiated)

If you are human, leave this field blank.

Notes for completing the Request form (above);

Fees are not claimable.

Email is used to send the link for telehealth sessions – use email that is on the device you want to use for telehealth sessions.

Name should be what you would like to be called. Your legal name is not required.

Phone number is mostly used to sms appointment times or other important information

Town, Post code, State, is used to determine time zones for contact and appointment scheduling

Reason for requesting therapy is included to ensure I am the right person to assist.

Fee Tier selection, please undertake your own calculations; If your income after tax and rent/mortgage ON THE HOUSE IN WHICH YOU RESIDE is greater than $1540 per fortnight then the fee tier is $120 per session. I keep my cost low so I can work with people from all walks of life – if you can afford more feel free to offer!

Notes for completing the Request form (above);

If you have questions you would like answered before starting therapy, I would be happy to answer them. Use this form….

Thanks for visiting.