MELBOURNE ART THERAPY STUDIO
Abbotsford Convent Arts Precinct
Convent Building
Studio C2.26 1 St Heliers Street
Abbotsford Vic 3067
Ph: (03) 8415 0052

Individual Art Therapy request

Name:

Address

Date of Birth

Day:

Month:

Year:

Phone (home):

Phone (mobile)

What are you hoping to get out of art therapy ?

Would you like to work on any of the following areas?

Confidence & self-esteem
Anxiety

Depression
Anger
Stress & relaxation
Sexuality & gender
Trauma
Addictions
Personal development
Communication
Trust
Managing conflict
Intimacy/sexual challenges
Parenting
Separation
Divorce
Blended families
Step-parenting

Grief / Bereavement
Illness
Other

Is there anthing you would like your therapist to know? eg: Illness, disability, chronic pain. Please specify.

Are you currently having treatment for your illness? Please specify. eg. medication, other forms of therapy.

Where did you hear about us?

Are you eligible for concession price?

ie. full time student, pensioner

What days & times are you available?

Preferred method of contact

"I would like find out more before I commit to a session"

YES

"I have read and understood the INFORMATION FOR NEW CLIENTS form"

YES

INFORMATION FOR NEW CLIENTS

PLEASE SUBMIT AND WE WILL CONTACT YOU TO ARRANGE A SESSION OR ANSWER QUESTIONS