headspace Rosebud Online Request Form

Welcome to headspace Rosebud

Online Request Form

This information is collected so we can commence the process of responding to your request for support and it will help us to inform the next steps for the care you may need.

There are some questions that you are required to answer to submit the form – we have labelled these with an asterisk (*).

Please answer as many questions as you can!

Name*

First NameLast Name

Name on Medicare card

Pronouns

Gender *

* Trans and Gender Diverse people are welcome at this service

Date of Birth*

Date

Please tell us what is the reason for contacting headspace Rosebud?*

What would you like help with?

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email

example@example.com

Mobile Phone Number*

Please enter a valid phone number.

Is this your mobile phone number?

YesNo

If no to the above, can we call or send SMS reminders to this number?

Please tick here if you do NOT want to receive SMS reminders:

Tick here

Home Phone/Other

Please enter a valid phone number.

Contact Preference

Phone CallSMSEmail

Do you (or your family) identify as Aboriginal and/or Torres Strait Islander?*

AboriginalTorres Strait IslanderBoth Aboriginal and Torres Strait IslanderNeither Aboriginal or Torres Strait Islander

Country of Birth (if other than Australia):

Cultural Identification (if other than English/Australian):

Do you need access to an interpreter?

YesNo

If yes, what is you preferred language?

Medicare Card:
Number Reference (number next to name) Expiry Date

Health Care Card:
Expiry Date

Do you have a current GP/doctor?

YesNo

If yes, please fill in the below information:
Practice Name Doctors Name Phone Number

Do you have any medical conditions that we should be aware of?

YesNo

If yes, please list here:

Are you allergic or sensitive to any medication?

YesNo

If yes, please list here:

Do you have any food or other allergies?

YesNo

If yes, please list here:

Young Person's Next Of Kin (Closest Relative or Guardian - Must be over the age of 18)
First Name* Last Name* Phone Number* Relationship*

Emergency Contact

Tick here if your emergency contact is the same as your next of kin contact listed above

Young Person's Emergency Contact Information if different from above
First Name Last Name Phone Number

Collection and use of your personal information

YSAS (including the headspace Frankston and headspace Rosebud programs) needs to collect personal information from you (such as personal, family and medical details) so we can give you quality health care, and we need your permission to collect and keep this information.

Head to the 'Client Privacy, Rights and Responsibilities and Making a Complaint' section on our website to read further important information about confidentiality and your rights and responsibilities when accessing headspace Rosebud services

Click HERE

Consent to collect and hold your information

I have read the information for the collection and use of my personal information and understand why my information must be collected.

YSAS has a Privacy Policy that conforms to the Privacy Act 1998 (Cth) and all other relevant Government laws and regulations.
Some of the participating agencies are also required to comply with the Freedom of Information Act 1982.
I understand that I do not have to give information, but if I don’t this might limit the range of services available to me

I understand that I can withdraw or change my consent at any time.

Are you making this referral on behalf of a young person?*

YesNo (I am referring myself)

If you are making this referral on behalf of someone else, what is your relationship with them?

If yes to the above, is the young person aware of this referral?

YesNo

Name

First NameLast Name

Contact Number

Date*

Date

headspace National Youth Mental Health Foundation is funded by the
Australian Government Department of Health

headspace Rosebud

825 Point Nepean Rd, Rosebud VIC 3939

Phone: 5925 9464

Email: headspace@headspacerosebud.org.au

By submitting this form, I am consenting to headspace Rosebud making contact with myself and/or the young person directly.

Young Person's Details

Contact Details