headspace | Self referral form

  • Self Referral Form:

    Good on you for making it this far. Please complete this form if you are referring yourself. This form won't take you very long. Some areas below are marked with a red asterisk and are essential to fill out. Young people aged 12-25 are eligible for support from headspace Echuca.

  • You can get support for your mental health by creating a headspace account at headspace.org.au, or you can peak to someone 1-on-1 via chat, email, or over the phone at eheadspace.org.au or 1800 650 890

    If you are in immediate risk, please contact Bendigo Psychiatric Triage on 1300 363 788, this number is contactable 24 hours a day, 7 days a week or call 000.

    headspace Echuca is not a crisis service.  

    If you need to speak to someone urgently: 

    Lifeline 13 11 14

    Kids Helpline 1800 551 800

    Suicide Call Back Service 1300 659 467

     

    PLEASE NOTE: HEADSPACE SERVICES ARE FOR YOUNG PEOPLE BETWEEN THE AGES OF 12-25

  • Referrals will be responded to within 2 working days. If you have not recieved a referral acknowledgement, please call us on 5485 5048.

  • Are you referring yourself?*

  • If you wish to refer someone else please go to the headspace Echuca Family, Friend or Professional Referral Form

  • Have you received services from headspace Echuca in the past?*
  • Date of Birth*
     - -
  • Gender*
  • Pronouns

  • Sexual Orientation*
  • Are you Aboriginal or Torres Strait Islander?*
  • If you are under 16 years of age, are your parents/carers aware of this referral?*
  • Do you need an interpreter?*
  • Is there a family member or worker you would like us to speak to?*
  • Do you have GP/ Doctor ?*

  • If you answered yes please provide details below:

  • Do you provide consent for us to contact your GP?

  • Emergency contact

    It is important that we have a trusted adult listed as an emergency contact. We will only contact this person if we have concerns for your safety and wellbeing.
  • If you are over 18, do you give us permission to contact this person if we cannot contact you?

  • Reason for contacting headspace Echuca

    Please select the options below that match your situation.
  • *

  • Additional comments

    Is there anything else you think we should know about? Tell us more here.
  • How did you hear about headspace Echuca?*

  • Your privacy is important to us. This information will be kept confidential and used only to give you the best care possible.

     

    https://headspace.org.au/eheadspace-privacy-policy/

     

  • Please note: Referrals will be responded to within 2 working days. If you have not recieved a referral acknowledgement, please call us on 5485 5048.

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