Registration 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.

"*" indicates required fields

About You*

I am enquiring for myself, as I support someone with mental health challenges

I am a parent / guardian of a young person. The young person could benefit from HelpingMinds services

I am a service provider referring someone else to HelpingMinds

I am interested in psychosocial support for myself

Your Details

Name*

First Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Date of Birth*

Phone*

Email*

Organisation

Role

Your relationship to the person you are supporting*

I am the parent

I am the grandparent

I am the guardian

I am the partner

I am the child

I am a friend

Other

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 Phone

By Email

How did you learn about HelpingMinds?

What first led you to become aware of HelpingMinds?*

Services

Interested in*

Not Sure

Carer Advocacy

Carer Respite

Counselling

Carer Peer Support

Workshops

Support Groups

Interested in*

Not Sure

Counselling

Mentoring

Workshops

School Holiday Program

Interested in*

Cultural Background

Do you identify as Aboriginal or Torres Strait Islander?

Aboriginal, but not Torres Strait Islander

Torres Strait Islander, but not Aboriginal

Aboriginal AND Torres Strait Islander

NEITHER Aboriginal OR Torres Strait Islander

Prefer not to say

Do you identify as culturally and linguistically diverse?

Yes

Prefer not to say

Do you require an interpreter?

Yes

Dialect

Details of the person you are referring

Is the person you are referring a child?*

Yes

Name (of person you are referring)*

First Last

Date of birth (of person you are referring)*

Contact Number (of person you are referring)*

Email Address (of person you are referring)

Address (of person you are referring)*

Suburb*

Postcode*

Name of Parent / Guardian of child you are referring

First Last

Contact Number for Parent / Guardian*

Email Address for Parent / Guardian

Does the parent give consent for this referral?*

yes

Please provide details of why you are submitting this referral*

Child's Details

Child's Name*

First Last

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 challenge.

Is impacted by a family member or friend living with a mental health challenge

What is the service you are seeking?

Services*

NDIS

Psychosocial support services (South Metro Area)

Do you have an existing NDIS Plan?*

Yes

What is your NDIS plan number?

Upload a copy of your NDIS plan

Max. file size: 128 MB.

Do you have a formal diagnosis?*

Yes

If yes, please state your diagnosis*

Do you have a guardian?*

Yes

Guardian's name*

Guardian's Phone Number*

Guardian's Email*

Do you identify as having any disabilities, impairments or conditions?*

Yes

Intellectual/learning

Yes

Psychiatric

Yes

Sensory/speech

Yes

Physical/diverse

Yes

Each fortnight we email a 'What's On Guide' and each month we email out a "HighLights' newsletter. Would you like to be added to the mailing list for these?*

Yes

CAPTCHA

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.

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.

Registration Form

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

Your Details

How did you learn about HelpingMinds?

Services

Cultural Background

Do you require an interpreter?

Details of the person you are referring

Child's Details

What is the service you are seeking?

Learn more about mental health conditions