Flourishing Brains Pre-Qualification Form

Flourishing Brains Pre-Qualification Form
Welcome – We're So Glad You're Here

Thank you for your interest in Flourishing Brains.
This short pre-qualification form helps us understand where things are currently at for your child and family, and whether our services are the right fit at this time.

Please complete the form as honestly and thoroughly as you can. If it seems like we may be able to support you, you'll receive a follow-up email with helpful next steps, including a link to book a free 10-minute discovery call with Dr Liana (founder of Flourishing Brains).

If you have any questions along the way, you're welcome to reach out at hello@flourishingbrains.com.au
Section 1: Parent & Child Details
Child's Full Name

First NameLast Name
Parent #1 Full Name

First NameLast Name
Parent #2 Full Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Child's DOB

DayMonthYear
Date
Where are you located (suburb)?
NDIS Status
Section 2: Your Child’s Needs & Goals
What brings you here?
Please share your child’s main challenges, any diagnoses, and your top 1–3 goals or priorities for their development and wellbeing.
How did you hear about Flourishing Brains?
(e.g., podcast, book, friend, practitioner)
Which services are you considering?
Section 3: Readiness for Care
Our care is most effective when key foundations are in place. Please answer honestly—this helps us guide you with care and clarity.
Are you within 60 minutes of Point Lonsdale, VIC?
Our care typically costs $300/week. Is this viable for your family?
Are you ready to commit to the following?
Have you already explored any of the following?
Would you be open to starting with these foundational steps first before progressing to functional neurology therapy?
Section 4: Final Reflection
What excites you about this approach and why does it feel like the right next step?
Is there anything else you’d like to share?
Should be Empty:

Flourishing Brains Pre-Qualification Form

Welcome – We're So Glad You're Here

Section 1: Parent & Child Details

Section 2: Your Child’s Needs & Goals

Section 3: Readiness for Care

Section 4: Final Reflection