Referral About You I am enquiring for myself, as I support someone with mental health challengesI am a parent / guardian of a young person. The young person could benefit from HelpingMinds servicesI am a service provider referring someone else to HelpingMindsI am interested in psychosocial support services [group enquiring-myself] Your Details First Name Last Name Email* Phone* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Date of Birth Your relationship to the person you are supporting I am the parentI am the grandparentI am the guardianI am the partnerI am the childI am a friendOther Once you have submitted the enquiry form our team will be in touch to ask some more detailed questions - how would you prefer to be contacted? By PhoneBy Email How Did You Learn About HelpingMinds? Internet SearchSocial MediaEventbriteRadioMedical Setting i.e. hospitalRecommended by another organisationRecommended by friend or familyPamphlet / PosterNewspaperOpen day / event / stallPrevious Client Services Interested in Not SureCarer AdvocacyCarer RespiteCounsellingCarer Peer SupportWorkshopsSupport Groups Cultural Background Do you identify as Aboriginal or Torres Strait Islander? Aboriginal, but not Torres Strait IslanderTorres Strait Islander, but not AboriginalAboriginal AND Torres Strait IslanderNEITHER Aboriginal OR Torres Strait IslanderPrefer not to say Do you identify as culturally and linguistically diverse? YesNoPrefer not to say [/group] [group parent-guardian] Your Details First Name Last Name Email* Phone* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Date of Birth Once you have submitted the enquiry form our team will be in touch to ask some more detailed questions - how would you prefer to be contacted? By PhoneBy Email How Did You Learn About HelpingMinds? Internet SearchSocial MediaEventbriteRadioMedical Setting i.e. hospitalRecommended by another organisationRecommended by friend or familyPamphlet / PosterNewspaperOpen day / event / stallPrevious Client Services Interested in Not SureCarer AdvocacyCarer RespiteCounsellingCarer Peer SupportWorkshopsSupport Groups Cultural Background Do you identify as Aboriginal or Torres Strait Islander? Aboriginal, but not Torres Strait IslanderTorres Strait Islander, but not AboriginalAboriginal AND Torres Strait IslanderNEITHER Aboriginal OR Torres Strait IslanderPrefer not to say Do you identify as culturally and linguistically diverse? YesNoPrefer not to say Child's Details Child's Name Your relationship to child Child's Date of birth Which of the following best describes the child Is at risk of developing a mental health challengeIs impacted by a family member or friend living with a mental health challenge [/group] [group referring-someone] Your Details First Name Last Name Email* Phone* Organisation Role Once you have submitted the enquiry form our team will be in touch to ask some more detailed questions - how would you prefer to be contacted? By PhoneBy Email How Did You Learn About HelpingMinds? Internet SearchSocial MediaEventbriteRadioMedical Setting i.e. hospitalRecommended by another organisationRecommended by friend or familyPamphlet / PosterNewspaperOpen day / event / stallPrevious Client Services Interested in Not SureCarer AdvocacyCarer RespiteCounsellingCarer Peer SupportWorkshopsSupport GroupsNDISSchool Holiday Program Details of the person you are referring Name of person you are referring Is the person you are referring a child YesNo [/group] [group psychosocial-support] Your Details First Name Last Name Email* Phone* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Date of Birth Once you have submitted the enquiry form our team will be in touch to ask some more detailed questions - how would you prefer to be contacted? By PhoneBy Email How Did You Learn About HelpingMinds? Internet SearchSocial MediaEventbriteRadioMedical Setting i.e. hospitalRecommended by another organisationRecommended by friend or familyPamphlet / PosterNewspaperOpen day / event / stallPrevious Client Cultural Background Do you identify as Aboriginal or Torres Strait Islander? Aboriginal, but not Torres Strait IslanderTorres Strait Islander, but not AboriginalAboriginal AND Torres Strait IslanderNEITHER Aboriginal OR Torres Strait IslanderPrefer not to say Do you identify as culturally and linguistically diverse? YesNoPrefer not to say What is the service you are seeking? Services NDISPsychosocial support services (South Metro Area) Do you have a formal diagnosis? YesNo [/group] Each fortnight we email a What's On Guide and each month we email out a newsletter. Would you like to be added to the mailing list for these? YesNo
