Name *

First Name

Last Name

I am a current member of Victoria Police, Ambulance Victoria, MFB, CFA, or SES; *

Yes, I am

No

I understand that I may not attend group sessions in uniform; *

Yes, I understand

No

I understand that private and sensitive material may be discussed in group sessions and that the confidentiality of group members must be maintained at all times; *

Yes

No

I agree to Dr Thamizan Tucker contacting me prior to my first group session to ensure the program is suitable for my needs; and *

Yes, I agree

No

I understand that if Dr Thamizan Tucker determines that the group program is not suitable to my needs, I may be referred on to another service. *

Yes, I agree

No