Service Request Form

Use this form to say “hi” and request further contact – this information is not published or shared.

ServiceRequestForm

Your Name

First Name

Last Name

Your Email

Your mobile number

POSTCODE or timezone

Service Request Type

Any further information you wish to provide

Service Fee (45 minute session)

Standard (120AUD)

Reduced (60AUD)

Therapy Preference

Telehealth

Home Visit (+ $15 cost, location within 10km of Pt Lincoln PO)

Alternative (to be negotiated)

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

If you are human, leave this field blank.

Notes for completing the above form;

Most is self-explanatory however…

Post code or timezone, is used to determine time zones for me to make contact or appointment scheduling

RService Request Type is the reason you are writing to me…

eason 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 above form;

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

Thanks for visiting.