Community Engagement Request Form

Community Engagement Request Form

headspace Midland
If you require support to complete this form, please contact Community Engagement
on 08 9274 8860 or ce@headspacemidland.com.au
Date Form Completed*

DayMonthYear
Date
Name Of Organisation*
Contact Name*
Contact Email*
Contact Number*
Engagement Request Details
Name of Event*
Location of Event*
Address.
Where will the Event be?*

IndoorsOutdoorsUnknown/ Other
Request Date*

DayMonthYear
Please allow at least 2 weeks from request date.
Requested Start Time*

Minutes

AM/PM Option
Requested Finish Time*

Minutes

AM/PM Option
Type of Engagement*

Standard Presentation (60 minutes)Custom PresentationWorkshop or ActivityStallOther
Audience Type*

Young People aged 12-25TeachersParents & CaretakersOther
Age Group / Year Level
Please complete if you selected "Young People aged 12-25".
Audience Size*

Under 10 PeopleBetween 10-30Between 30-50Over 50 People
Are there any mental health initiatives or concerns that we should be aware of?*
For Schools Use Only.
What topics are relevant to your group?*

AnxietyBody Image and Eating DisordersBullyingDepressionEmploymentGrief and LossSchool TransitionsStressStudyingSexual HealthWellbeingOther
If you selected other, please advise:
What equipment is available?*

ChairsMarqueeMicrophoneProjectorSound for PresentationTableOther
If you selected other, please advise:
Is there anything else we should know?*
For Schools Use Only.
Please upload any relevant files here:

Cancelof
Should be Empty:

Engagement Request Details