headspace Midland YRG Application Form

headspace Midland Youth Reference Group Application Form 2025
The YRG is made up of young people that are passionate about mental health and well-being. The YRG aims to provide young people with the opportunity to co-design headspace services, provide a platform for the voice of young people to be heard and acted upon, provide opportunities to develop skills and knowledge, and lead projects.

For more information or to discuss your application, please contact Community Engagement on 08 9274 8860 or ce@headspacemidland.com.au
Full Name*

First NameLast Name
Preferred Name
Pronouns*
Date of Birth*

DayMonthYear
Date
Phone Number*
Email*
example@example.com
Suburb of residence*
Where were you born?*
Do you identify as:*

Aboriginal and/or Torres Strait IslanderCulturally and Linguistically DiverseLGBTQIA+NeurodiverseDisabledNone of the AboveOther
About You

To help us learn a bit more about you, please share some information about your hobbies, ambitions, passions and interests.
Please tell us a bit about yourself.*
Minimum of 20 words.
Why are you interested in joining the headspace Midland Youth Reference Group?*
Minimum of 20 words.
What does youth mental health mean to you, and why is it important?*
Minimum of 20 words.
How did you hear about the YRG?*
Minimum of 20 words.
Skills and Strengths
What skills, experiences, or perspectives do you bring that you think would benefit the YRG?*
Have you been involved in any advocacy, volunteer, or leadership roles before? If so, please describe your experience.*
Are there any specific mental health issues or community challenges you are particularly passionate about addressing?*
Goals and Vision
What do you hope to gain from being part of the YRG?*
If you could create a project or campaign to support youth or community health, what would it focus on and why?*
Additional Information

If you are comfortable, please answer the following questions.
Is there anything we should know that might affect your engagement in the YRG?
(Example: disability, impairment, injury)
Do you have any accessibility requirements? (If yes, please provide more information)
Do you have any dietary requirements? (If yes, please provide more information)
Do you have any allergies or medical conditions we should be aware of? (If yes, please provide more information)
Do you and/or a family member identify as having/had a mental illness?
Commitment and Availability
The YRG requires attending monthly meetings, events, and occasional workshops. Are you able to commit to this level of involvement?*
Do you foresee any barriers or challenges to participating fully in the YRG, and how can we support you?
Emergency Contact Details

Please provide details for at least one emergency contact.
Emergency Contact #1*

First NameLast Name
Relationship to you*
Example: Mother, Father, Guardian, Support Worker
Phone Number*
Email*
example@example.com
Emergency Contact #2

First NameLast Name
Relationship to you
Example: Mother, Father, Guardian, Support Worker
Phone Number
Email
example@example.com
Should be Empty:

headspace Midland Youth Reference Group Application Form 2025

About You

Skills and Strengths

Goals and Vision

Additional Information

Commitment and Availability

Emergency Contact Details