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Family Intake Form

Child Counselling, Developmental Screening & Mental Health Support · Brisbane & Ipswich, QLD

WellfirstKIDS

1. Tell us about your family

Your name

Relationship to child

Email address

Phone number (optional)

2. About your child

Child's first name

Age

School grade / level

3. Celebrating your family's heritage

Cultural background

Languages spoken at home

We honour and respect all cultural backgrounds.

4. What type of support are you interested in? (tick the option that best matches your situation)

TALK: Emotional wellbeing (counselling)
GROW: Development & life skills
CONNECT: Mentoring & community
MOVE: Movement & wellbeing
Allied Health Assistant (AHA) support
I'm not sure
I'm enquiring for a school or community organisation

5. Funding & payment (seeking NDIS or another funded pathway?)

Yes — NDIS funding
Yes — another funded pathway
No — direct family payment

6. Share your story with us (your child's strengths & any areas of concern)

7. Making this comfortable for everyone (any accessibility needs or preferences?)

8. How would you like us to connect with you?

Phone call
Email
Either is fine