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About Minds of All Kinds Psychology
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Heidelberg
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Heidelberg Clinic
Fairfield Clinic
Contact
New Client Enquiry Form
External Referral Form
📞
03 7042 9722
New Client Enquiry Form
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Name of client
*
First
Last
If you are requesting an appointment for your child, please enter their details here.
Date of birth
*
Name of parent/guardian
First
Last
Phone number
*
Email
*
Service type (tick all that apply)
*
Autism Assessment
ADHD Assessment
Cognitive/Educational Assessment
Therapy
Parenting support
Group
Other
Referral source
*
GP/Paediatrician
School/teacher
Self-referral
NDIS Support Coordinator
Other
Funding Information
*
Medicare (e.g., Mental Health Care Plan)
NDIS – Self-Managed
Private Health Insurance
Private (self-funded)
Other
birth Referral Funding
Preferred Location
Heidelberg
Fairfield
Telehealth
Reason for Referral / Main Concerns
*
Please describe the main reasons you are seeking support (e.g. anxiety, behaviour, developmental concerns, family stress, school difficulties, trauma, relationship challenges, etc.):
How soon are you looking to book an appointment?
*
As soon as possible
Within 1-3 months
Within 3-6 months
Unsure/flexible
Do you have any preferences for the psychologist you see?
*
Is there anything else we should know?
*
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