Request to Cancel an Appointment

Please note:This form constitutes as a request to cancel your appointment. It is your responsibility to ensure you complete all actions on this form and submit the form successfully. Cancellation fees may apply if you are providing less than 24 hours notice of your cancellation.

    Your Details

    First Name *
    Last Name *
    Email *
    Phone Number *

    Your Appointment

    Appointment Time *
    Appointment Date *
    please check that time and date are correct
    Psychologist *
    Reason for Cancellation*

    Would you like to book in another appointment?
    How would you like to re-book?*
    Please check the details of this request
    Disclaimer
    It is your responsibility to ensure you complete all information on this form correctly. When this form is successfully submitted, you will be taken to a confirmation page, and you will also receive an email confirming the receipt of your cancellation request.