Pre-Program Questionnaire
To find out whether your child might be suitable for any Resilience Kit private mental health service, please complete the form below.

This form is a screening tool and does not confirm your child's enrolment. After receiving your information, we will contact you to confirm suitability.

If you have any questions, please contact us on 0481 369 446. Thank you.

View our Privacy Policy:
www.resiliencekit.com.au/mental-health/privacy-policy/

Have you viewed the session outlines?
Resilience Kit | Kids + Teens: https://www.resiliencekit.com.au/cognitive-behavioural-therapy/kids-teens/
Resilience Kit | Family: https://www.resiliencekit.com.au/cognitive-behavioural-therapy/family-resilience-program/

Child's name *
Your answer
Child's age *
Your answer
Child's date of birth *
Your answer
Child's school and year group
Your answer
Your name *
Your answer
Your phone number and best time to reach you *
Your answer
Your email address *
Your answer
Your suburb
Your answer
Please list any concerns you have about your child. *
Your answer
Is your child currently receiving any additional support? *
Your answer
What are your child's strengths? *
Your answer
What are your child's hobbies and interests? *
Your answer
Is there anything else that you can think of that can help us understand where your child is at? *
Your answer
Which program are you interested in? *
Required
What would you like your child to achieve by the end of the program? *
Your answer
How did you hear about us? *
Required
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