Expression of Interest Form

Please note: submitting this form does not guarantee eligibility for this service

If you require immediate or urgent support, please contact your local mental health crisis service or helpline

Thank you for your interest in Joel Moffat Psychology. Please complete this form as best you can (required fields are marked with a red asterisk) then press submit to send with the security of HIPAA compliant encryption.

Please be aware that submitting this form does not guarantee eligibility for this service. Once you have submitted the form, Joel Moffat will review this information to determine his suitability to provide services to you via the online clinic. This decision is based upon Joel's availability at the time of your expression of interest, his strengths and experience, your location, as well as the logistics and limitations of an online therapy space. This decision is not a reflection of you, your value, your worth, or your need for support. Please allow up to 2 weeks between submitting the form and receiving contact from our admin team.

Please note, Joel Moffat Psychology is not a crisis service; there may be some time between reaching out and receiving a response. We may also have a waiting list for services. As such, if you require immediate support, please consider reaching out to your local crisis service, helpline, or see your General Practitioner for referral options. If your life is currently in danger, call 000 (if you are in Australia) or go to your local emergency department to seek urgent medical attention.

Please be aware that Joel is only able to offer psychology services (including therapy) to people residing within Australia. He is able to offer consultancy services to people outside of Australia, which tend to be educational rather than therapeutic in nature.

You may be eligible for a Medicare, NDIS or Private Health rebate for accessing this service.

Psychology/Consulting

If you were referred by another health professional, please provide details below.

Have you engaged in other psychology/mental health services or coaching before? If yes, please specify

If you have previously engaged in psychology services/coaching, what was your experience like?

Why are you interested in accessing psychology/consulting with Joel Moffat? Why do you think our service might be the right fit for you?

What are your current therapy/coaching goals?

It is helpful if you can be specific here, your answers will help us determine whether this service is the right fit for you.

Have you received a mental health diagnosis?

Yes

I'm a professional seeking consultancy

If yes, please provide details

e.g., Depression, Anxiety, PTSD, Borderline Personality Disorder

Have you ever been hospitalised for mental health reasons?

Yes

Yes, not in the last 2 years

I am a professional seeking consultancy

Do you identify as/have you been formally assessed as gifted and/or neurodivergent?

Yes, Gifted

Yes, Autistic

Yes, Highly Sensitive/Sensory Processing Sensitivity

Yes, Attention Deficit Hyperactivity Disorder

Yes, Other

Prefer not to specify

Your details

First name

Last name

If you wish to, please tell us your pronouns

Phone

Age

Where are you located? (Please provide State/Province and Country)

Is there anything else you feel is important to include in this expression of interest?

Joel Moffat Psychology is an online clinic that provides telehealth consultations

I have a laptop, desktop, tablet, or other device with a camera, microphone, and speakers

I have access to steady, fast internet connection

I have access to a quiet, comfortable, private space that I can use for online sessions

I have a safe living environment that allows me to feel comfortable accessing online sessions

I understand that by submitting this data I agree to the Privacy Policy and Terms & Conditions as stated in the links below

https://www.websitepolicies.com/policies/view/ClPCwFCe https://www.websitepolicies.com/policies/view/0iOCqgsJ

Your information will be encrypted.

Expression of Interest Form

Please note: submitting this form does not guarantee eligibility for this service

Your details

Please note: submitting this form does not guarantee eligibility for this service

Joel Moffat

Clinical Psychologist, Joel Moffat Psychology