Please complete this form so our psychologist can understand what you are looking for and determine the most appropriate next step. Completing this form does not constitute an appointment.
Full name* Preferred name Email address* Phone number* Suburb / area Who is the enquiry for?* —Please choose an option—MyselfMy child / adolescentMy partner and meMy familySomeone I support
Please select the service that best matches what you are looking for.
—Please choose an option—Adult TherapyDepression & Anxiety SupportTrauma CounsellingStress & BurnoutChild & Adolescent PsychologyFamily & Couples TherapyParent SupportLife Transitions & AdjustmentChronic Health & Wellbeing PsychologySupport for Life-Changing DiagnosesADHD Assessment & CoachingRapid Transformational Therapy (RTT®) HypnotherapyI'm not sure which service is right for me
What has prompted you to seek support at this time?* What would you most like help with or hope to achieve through therapy?
Have you previously seen a psychologist, counsellor or other mental health professional?*
YesNo If yes, please briefly tell us about your previous support.
Are you currently receiving support from another mental health professional?*
YesNo If yes, please provide any relevant details.
If you are experiencing an immediate mental health crisis or believe you may be at risk of harming yourself or someone else, please do not wait for a response to this form. Lifeline: 13 11 14 (24/7) Mental Health Emergency Response Line: 1800 676 822
Are you currently experiencing an immediate mental health crisis, or do you feel you may be at risk of harming yourself or someone else?*
NoI am distressed but currently safeYes
Preferred appointment format*
In personTelehealthEither
Preferred availability
Weekday morningsWeekday afternoonsWeekday eveningsSaturdayFlexible
How were you referred to State of Mind? —Please choose an option—GP / medical practitionerAnother health professionalFamily or friendGoogle / online searchSocial mediaReturning clientOther
Do you have a Medicare Mental Health Treatment Plan?
YesNoNot surePrefer not to say
Do you intend to claim through private health insurance?
Is there anything else you would like the psychologist to know before contacting you?
I understand that this is an initial enquiry and not an appointment or crisis service. I consent to State of Mind Practice contacting me regarding this enquiry and understand that the information I provide will be handled in accordance with the practice's privacy policy.
Please enter an answer in digits:
two × two =
