MindWare Psychology Empowering Horizons Group Therapy Programs - Expression of Interest Form

Thank you for your interest in the Empowering Horizons Therapeutic Group Programs run by MindWare Psychology. Please complete this form to express an interest (there is no obligation at this stage). Please complete an EOI for EACH client e.g. if you have more than one client attending please complete the form for each client. If you are an adult please complete for yourself. When we have received your EOI we will contact you to book you in for an intake appointment (no obligation) to discuss therapy needs and review if the program is a good fit for you and your goals.

Question Title

* 1. What program are you interested in?

Junior Social Connections Program (Primary School Age 6 - 12)

Senior Social Connections Program (High School Age 13 - 17)

Adult Social Connections Program (18+)

Other (please specify)

Question Title

* 2. Name of the Participant (person applying to attend the program):

Question Title

* 3. Date of Birth of the Participant

Question Title

* 4. Parent/Carer/Representative Contact Details for the participant:

Name:

Phone:

Email:

Question Title

* 5. We want to support the participant with their therapy goals and work towards matching them with other participants who have similar goals. What are the goals for the applying participant?

Question Title

* 6. Does the participant currently see a therapist e.g.: Psychologist/Social Worker/Counsellor? If they are, what are their details? And does the participant have current therapy goals/assessment needs that we can support them with?

Question Title

* 7. We want to help you with processing your payments. Please select which group best defines your funding source for this therapy program?

Privately Paid

National Disability Insurance Scheme (NDIS)

Child Safety

Other (please specify)

Question Title

* 8. If you are NDIS funded, please indicate how the NDIS plan funds are managed:

NDIS Self Managed

NDIA Managed

NDIS Plan-Managed: Please specify the name of the Plan Manager

Question Title

* 9. We want to support the participant and also undertake a risk assessment to support all participants on our group programs. Does the participant have any behaviours that we need to take into account which could increase the risk for other participants in the program? (this does not necessarily exclude them but rather helps us support your participant to have success on the program):

Question Title

* 10. Sleeping Away from Home:
Sleeping away from home can be hard for some - will the participant have any sleep issues that would be helpful for us to know whilst they are on the residential program? Have they stayed away from home before?

Question Title

* 11. Does the participant currently take medication? If they do, could you please give us a brief summary of the medications (we will ask for more information when accepted into the program):

Question Title

* 12. The success of our Programs are designed around the care we take with trying to match the individual needs of participants and the overall balance of the group. Our staffing ratio is 1:3 and as such we have limited places in our program. When you receive your offer of a place in the program we ask that a deposit of $500 is made to confirm your acceptance. This will secure the participant's booking. If you are using a funding source such as NDIS we will then issue an invoice for the group program costs to your identified funding source. We will refund the $500 deposit upon receiving full payment from your identified funding provider. If paying privately an invoice for the cost difference will be made to you directly. Please note deposits will not be refunded for a change of mind. If you have any questions or concerns please comment below:

Question Title

* 13. When we have received your EOI we will contact you to book you in for an intake appointment (no obligation) to discuss therapy needs and review if the program is a good fit for you and your goals.

If you have any further questions please feel free to call our reception at MindWare Psychology on: 07 46 464953 or email contact@mindwarepsychology.com.au

Please comment below if you have any further comments you would like to make:

MindWare Psychology Empowering Horizons Group Therapy Programs - Expression of Interest Form

Question Title

* 1. What program are you interested in?

Question Title

* 2. Name of the Participant (person applying to attend the program):

Question Title

* 3. Date of Birth of the Participant

Question Title

* 4. Parent/Carer/Representative Contact Details for the participant:

Question Title

* 5. We want to support the participant with their therapy goals and work towards matching them with other participants who have similar goals. What are the goals for the applying participant?

Question Title

* 6. Does the participant currently see a therapist e.g.: Psychologist/Social Worker/Counsellor? If they are, what are their details? And does the participant have current therapy goals/assessment needs that we can support them with?

Question Title

* 7. We want to help you with processing your payments. Please select which group best defines your funding source for this therapy program?

Question Title

* 8. If you are NDIS funded, please indicate how the NDIS plan funds are managed:

Question Title

Question Title

* 10. Sleeping Away from Home:Sleeping away from home can be hard for some - will the participant have any sleep issues that would be helpful for us to know whilst they are on the residential program? Have they stayed away from home before?

Question Title

* 11. Does the participant currently take medication? If they do, could you please give us a brief summary of the medications (we will ask for more information when accepted into the program):

Question Title

Question Title

* 10. Sleeping Away from Home:
Sleeping away from home can be hard for some - will the participant have any sleep issues that would be helpful for us to know whilst they are on the residential program? Have they stayed away from home before?