Support Enquiry

Enquiry about support

"*" 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?*

Internet Search

Social Media

Eventbrite

Radio

Medical Setting i.e. hospital

Recommended by another organisation

Recommended by friend or family

Pamphlet / Poster

Newspaper

Open day / event / stall

Previous Client

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*

Not Sure

Carer Advocacy

Carer Respite

Counselling

Carer Peer Support

Workshops

Support Groups

NDIS / Pyschosocial Support

School Holiday Program

WA Recovery College

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

No

Prefer not to say

Do you require an interpreter?

Yes

No

Dialect

Details of the person you are referring

Is the person you are referring a child?*

Yes

No

Name (of person you are referring)*

First Last

Date of birth (of person you are referring)*

DD slash MM slash YYYY

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

no

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*

DD slash MM slash YYYY

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

No

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

No

If yes, please state your diagnosis*

Do you have a guardian?*

Yes

No

Guardian's name*

Guardian's Phone Number*

Guardian's Email*

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

Yes

No

Intellectual/learning

Yes

No

Psychiatric

Yes

No

Sensory/speech

Yes

No

Physical/diverse

Yes

No

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

No

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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