Who is making this referral?

Secure referral to The Kind Mind Co Pty Ltd

Tell us a little about the support you’re looking for. The Kind Mind team will review your enquiry and contact you to discuss fit, funding and the next step. This is not a crisis service. If you’re in immediate danger, call 000. For crisis support, contact Lifeline on 13 11 14.

Your details

Full name *

Preferred name

Phone number

Provide a phone number or email so the organisation can respond.

Date of birth

Gender

Address

Address line 2

Suburb

State

Postcode

How did you hear about us?

Therapy support

What would you like help with? *

Select every service that applies. A tick appears on each service you select.

What help is being sought? *

A short, practical summary is enough. Detailed clinical history can be discussed securely with the treating practitioner.

Appointment format: Telehealth

The Kind Mind Co Pty Ltd is a telehealth service. Sessions are provided securely, so clients can attend from across Australia.

Appointment preferences

Weekday appointments are available Monday to Friday, 9:00 am to 5:00 pm. These are preferences only and remain subject to therapist availability.

Preferred appointment day

Preferred appointment time

What are you looking for in a therapist?

For example, experience, communication style, cultural considerations or anything that may help us assess whether our team is a good fit.

Funding and referral details

You can ask to start support as soon as possible. Billing account details are set up later through a secure payment link, not in this public referral form.

I would like to start support as soon as a therapist is available.If the referral is accepted, the practice can use the billing contact below to send the next steps and a secure payment set-up link where needed.

How will the service be funded? *

Communication and accessibility

Communication preferences

Share the best way and time to communicate, or any accessibility requirements.

I may need an interpreter

Preferred language, if an interpreter is needed

Urgent risks or important safety information

Only include information the practice needs to triage this referral safely.

This referral form is not an emergency or crisis service and may not be monitored immediately. Call Triple Zero (000) if someone is in immediate danger.

Documents and anything else

Upload a referral, plan or relevant reportOptional

Only upload documents needed to assess this referral. PDF, Word, JPG, PNG and TXT files. Up to 12 files, 10 MB each and 25 MB combined. If a phone saves photos as HEIC, take a screenshot or export as JPG first.

Any information you would like us to know in advance

Optional. Please share only information that will help the team assess this referral or plan a safe first appointment.

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