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
Are you referring yourself?*

YesNo
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?*

YesNo
Legal Full name*

First NameLast Name
Preferred Name (optional, if different to above)

First NameLast Name
Date of Birth*

DayMonthYear
Gender*

MaleFemaleOther
Pronouns

She/herHe/himThey/themPrefer not to sayOther
Sexual Orientation*

Straight/ HeterosexualLesbianGayBisexualOther sexualityQuestioningChoose not to answerI don't know what these words mean
Address*

Street Address

Street Address Line 2

City/townState

Postcode
Phone number *
E-mail*
Are you Aboriginal or Torres Strait Islander?*

NoAboriginalAboriginal and Torres Strait IslanderTorres Strait IslanderPrefer not to say
If you are under 16 years of age, are your parents/carers aware of this referral?*

YesNoNA
Country of birth/ethnicity?*
Preferred language*
Do you need an interpreter?*

YesNo
If you are still in school, which one?*
Is there a family member or worker you would like us to speak to?*

Yes - If yes, please provide details belowNo
Name of family member
Name of worker
Contact phone number
Service / Agency
eg. School, case manager, support worker agency
What is this person's relationship to you?
eg. Mother, Grandparent
Contact phone number
Do you have GP/ Doctor ?*

YesNo
If you answered yes please provide details below:
Name of GP/Doctor Provider
Name of GP/Doctor Practice
Contact phone number
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.
Full Name*

First NameLast Name
Phone number *
Relationship to you*
If you are over 18, do you give us permission to contact this person if we cannot contact you?

YesNo
Reason for contacting headspace Echuca

Please select the options below that match your situation.
I'd like someone to talk toThings just aren't going very wellEmployment issuesSchool issuesFriendship issuesRelationship issuesPhysical healthFamily issuesAnxiety stressLow moodSexual healthTrauma/griefI need a mentor/coachAlcohol and other drugsHousing SupportSelf harmThinking of suicideI'm concerned about someone close to meOther
Additional comments

Is there anything else you think we should know about? Tell us more here.
Please provide a summary of your key concerns to help us better support you:*
How did you hear about headspace Echuca?*

School presentationSchool wellbeing teamCommunity eventSocial mediaFriends or familyOther
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.
Should be Empty:

Self Referral Form:

Emergency contact

Reason for contacting headspace Echuca

Additional comments