Request Further Information - Mind Medicine Clinic Treatment

Welcome to the Mind Medicine Australia Clinic.

Please complete this form to express interest in our groundbreaking treatment for Post-traumatic Stress Disorder (PTSD) and Major Depressive Disorder (MDD), or Treatment-resistant Depression (TRD).

The questions contained in the form are to guide our team of specialist clinicians in advising on the next steps.

Once we have received your form, we will be in touch to guide you through the assessment process.

"*" indicates required fields

Step 1 of 6

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Comments

This field is for validation purposes and should be left unchanged.

Step 1. Personal Details

Please provide your contact and background information so that our team can follow up if required.

First Name*

Last Name*

Date of Birth*

DD slash MM slash YYYY

Email*

Phone*

In which country do you currently live?*

State/Territory*

Step 2. Treatment Enquiry

We’d like to understand who you’re enquiring on behalf of and your general interest in treatment.

Are you enquiring about treatment for yourself or someone else?*

For myself

For someone else

Therapist wanting to be involved in treatment for patient

If for someone else, what is your relationship to the person?

Step 3. Funding and Cost

Therapy involves significant clinical support and highly trained staff. Treatment costs range from approximately $8,730 to $23,090, depending on the number of dosing sessions and the treatment type.
Medicare rebates and some private health fund contributions may apply. Limited assistance is also available through programs such as the NDIS, DVA, or Mind Medicine Australia’s Patient Support Fund (PSF). You can learn more about these options here.

Please confirm your ability to fund treatment before proceeding.

Can you cover the cost of treatment either privately or with the assistance of other funding options*

e.g. NDIS, DVA, MMA’s Patient Support Fund

Yes, I can cover the cost privately

Yes, with assistance from NDIS, DVA, or MMA’s PSF

Step 4. Diagnosis and Clinical History

To be eligible for treatment, patients must have a formal diagnosis of Treatment Resistant Depression (TRD) or Post-Traumatic Stress Disorder (PTSD).

Have you received a diagnosis of Treatment Resistant Depression (TRD) and/or Post-Traumatic Stress Disorder (PTSD)?*

Yes

If yes, who made the diagnosis?*

Please upload proof of diagnosis

e.g. referral letter, report, or summary (optional)

Accepted file types: pdf, jpg, png, doc, docx, Max. file size: 5 MB.

Have you previously tried medications for MDD/PTSD without adequate benefit?*

Yes

Are you currently participating in any drug interventional clinical trials, or have you participated in the past 6 months?*

Yes

Step 5. Treatment Location and Readiness

Our therapy programs are conducted in person at our Abbotsford (Melbourne) clinic. Patients must be able to travel and remain on-site for the duration of each dosing session (approximately 8 hours).

Are you able to travel to Melbourne for full-day dosing sessions at the Abbotsford clinic?*

Yes

Anything else you would like to share?

Optional comments (e.g., background, motivation, relevant medical info)

How did you hear about the clinic?*

Step 6. Consent & Confirmation

Before you submit your form, please confirm your understanding and consent to proceed with the screening process. Your data will be stored securely and treated as confidential in accordance with Australian privacy law.

Consent*

If paying privately, I confirm that I have funding for the treatment*

Consent*

I consent to be contacted electronically via email and mobile*

Consent*

I consent to the collection and use of my data throughout the screening process and am happy to receive updates from the MMA Clinic*

Consent*

I consent to clinic staff accessing my medical records and communicating with my treating professionals*

ADVANCE NOTICE OF ANY CANCELLATION OR POSTPONEMENT OF APPOINTMENTS: Your appointment is reserved specifically for you. We ask that you notify us at least 48 hours in advance to cancel or reschedule, allowing us to offer that time to another patient. Late cancellations will be subject to the full cost of their appointment.

Notice of Cancellation*

I agree to the Clinic's cancellation policy*

40 Turner Street, Abbotsford, VIC 3067.

03 9828 7566

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