Referral Form

HelpingMinds® provides mental health support services to the friends and family of someone with a mental health issue, and practical support services to people experiencing a mental health issue.

Carer support services: Counselling, advocacy, peer support, support groups, and workshops.

Mental health support services: National Disability Insurance Scheme (NDIS), Psychosocial support services (PHN South) and youth early intervention.

Please contact our team on 9427 7100 to discuss eligibility in our catchment areas.

Client Details
Name*
First Last
Date of Birth*
Gender
Phone*
Email
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Ethnicity
Do you require an interpreter?
- Yes
- No
Dialect
Reason for referral*
Referrer Details (if applicable)
Are you a GP who received our referral pack (Tonic Media)?
- No
- Yes
Name
First Last
Relationship to client
Organisation (if applicable)
Role (if applicable)
Phone
Email
Please note: The information you provide on this form may be requested and used by our funding bodies for the purpose of research, analysis and evaluation of this service. This data will remain strictly confidential and, in some circumstances, de-identified.
I (the client) agree that HelpingMinds^® may contact my relevant service providers to gather additional information to assist with my referral if needed*
- Yes
- No
I (the client) consent to this form being submitted to HelpingMinds^® and for HelpingMinds^® to contact the client to complete an intake assessment*
- Yes
- No
Youth Referrals Only
Signed consent is required to process youth referrals
NAME OF PARENT / GUARDIAN 1
First Last
Relationship to child
Date of birth
MM slash DD slash YYYY
Phone
Email
SIGNATURE OF PARENT / GUARDIAN 1
Date
MM slash DD slash YYYY
NAME OF PARENT / GUARDIAN 2
First Last
Relationship to child
Date of birth
MM slash DD slash YYYY
Phone
Email
SIGNATURE OF PARENT / GUARDIAN 2
Date
MM slash DD slash YYYY
- I wish for HelpingMinds^® counselling to proceed without the second Parent/Guardian consent
- I am unable to get the second Parent/Guardian consent because:
NDIS/Psychosocial support services referrals only
What is the service you are seeking?
- NDIS
- Psychosocial support services (PHN South)
Do you have an existing NDIS Plan?
- Yes
- No
If yes, what is your NDIS plan number
Upload a copy of your NDIS plan
Max. file size: 64 MB.
Do you have a formal diagnosis?
- Yes
- No
If yes, please state your diagnosis
Do you have a case manager?
- Yes
- No
Name of case manager
Agency (If known)
Phone
Email
Do you have a guardian?
- Yes
- No
Guardian's name
Phone
Email
Do you have a carer?
- Yes
- No
Carer's name
Phone
Email
Do you self-identify as having one or more of the following disabilities, impairments or conditions?
Intellectual/learning
- Yes
- No
Psychiatric
- Yes
- No
Sensory/speech
- Yes
- No
Physical/diverse
- Yes
- No
None (no disability/impairment/condition)
- Yes
- No

HelpingMinds^® respectfully acknowledge that we work on Aboriginal land and pay our respects to community members and Elders, past and present. Individuals pictured are models and are used for illustrative purposes only.

HelpingMinds^® is committed to embracing diversity and eliminating all forms of discrimination in the provision of health services. HelpingMinds^® welcomes all people irrespective of ethnicity, lifestyle choice, faith, sexual orientation and gender identity. For more information, see our Diversity Statement.

HelpingMinds^® prides itself on being an accessible and inclusive organisation, ensuring everyone who needs support is able to access the right service and receive the help they need. If you require accessible locations, an interpreter or translator services, please contact us. For more information, see our Disability Access and Inclusion Plan.

HelpingMinds^® respectfully acknowledge that we work on Aboriginal land and pay our respects to community members and elders, past and present. Individuals pictured are models and are used for illustrative purposes only.

Referral Form

Please contact our team on 9427 7100 to discuss eligibility in our catchment areas.

Client Details

Referrer Details (if applicable)

Youth Referrals Only

NDIS/Psychosocial support services referrals only

Learn more about mental health conditions