"*" indicates required fields Please complete the form below. Please see our fee schedule prior to sending a new client request. Is the assessment for yourself or someone else?* Myself Someone else What is your name?* What is the name of the person you are making the assessment request for? What is your relationship with this person? Parent Family Member/Relative Primary Caregiver Support Worker Other What is your mobile number?* What is your email address?* What is the date of birth for the individual requesting assessment?*Day12345678910111213141516171819202122232425262728293031Month123456789101112Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920 What is the address of the individual requesting assessment?*Suburb*Postcode* If a child, are there any shared care, out of home, child safety or custody arrangements in place?If a child, name of kindergarten/school/childcare centre What are the goals/purpose of engagement with Young Minds?* Please tell us which type of allied health / therapy services the individual has previously accessed? Occupational Therapy Speech Pathology Psychology Physiotherapy Please select all that apply. Do you require a language interpreting service?* No Yes What language service do you require interpretation for? Please provide additional information that will assist us in linking you in with the right practitioner.* Will you be accessing Young Minds services under a Mental Health Care Plan?* Yes No
