If you interested in an appointment with YoungMinds, please complete the form below:Is the appointment for yourself or someone else? Myself Someone else What is your name? What is the name of the person you are making the appointment for? What is your relationship with this person? Parent Family Member/Relative Primary Caregiver Support Worker What is the date of birth for the individual requiring support?Day12345678910111213141516171819202122232425262728293031Month123456789101112Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920 What is your suburb of residence? Telehealth appointments offer greater convenience and flexibility than face to face appointments and removes the need to travel into Clinic. Would the client like to access our services via Telehealth?* Yes No Would you also like to register for face to face appointments? Yes No For face to face appointments, please indicate which of our locations you are able to attend. Select All Stafford The Gap Northlakes Redcliffe Please select all that apply. What type of therapy are you enquiring about? General Counselling Occupational Therapy Speech and Language Pathology Group Programs Psychological Assessment (Cognitive, Academic, etc.) Eating Disorders and Weight Management Parenting Support Please select all that apply. What is your mobile number?We send SMS reminders for appointments. What is your best email address? What is your funding type? Self-funded Private Health Doctors Referral with Mental Health Care Plan National Disability Insurance Scheme (NDIS) Please select one. Please provide a description of what you would like to see us about. Do you have a preference regarding the gender of your clinician? Female Male Don’t mind Do you require a language interpreting service? (Please note an interpreter service is not available for telehealth appointments.) No Yes What language service do you require interpretation for? Do you have any additional questions or comments?
