"*" indicates required fields If you interested in an appointment at YoungMinds, please complete the form below.Your child's age is:* 0 – 4 5 – 10 11 – 14 15 years or older What is your name?* What is your child's name?* What is the date of birth for the child 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 Which clinic locations are you willing to visit? Stafford The Gap Northlakes Redcliffe Select AllPlease 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.) Disordered Eating and Weight Management Parenting Support Early Intervention (Under 5 years) What is your mobile number?* We send SMS reminders for appointmentsWhat is your best email address?* Enter Email Confirm Email What is your funding type?* Self-Funded Private Health Doctors Referral National Disability Insurance Scheme (NDIS) Other Select one Are there any court orders in place?* Yes No Please be aware, YoungMinds or it’s Clinicians do not provide letters or reports for the Courts unless Subpoenaed. Should you be after this type of support please look up Forensic Psychologists in your area. 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 or your child require a language interpreting service? (Please note an interpreter service is not available for telehealth appointments.)* Yes No Do you have any additional questions or comments?