headspace Mount Gambier referral form

headspace Mount Gambier Referral Form
headspace provides FREE services for people aged 12 - 25, supporting young people with their mental health, physical health, alcohol & other drug support and work & study support.

headspace is not a crisis service or an acute mental health service.

For emergency mental health support or in crisis situations, call 000.

Don't forget to gain consent from the young person and parent/caregiver (if under 16).

Ensure all sections in the form below are completed, and please contact headspace if you have any questions about how to complete this form.

171 Commercial Street East Mount Gambier

8725 0443

headspacemgadmin@unitingcommunities.org
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1. Young Persons details:
Given Name*

First NameLast Name
Preferred name/Pronouns

Preferred name (if different to given name)Pronouns (he/him, she/her, they/them etc.)
Gender
eg. female, male, trans male, trans female, non-binary, gender diverse, other
Date of birth*

DayMonthYear
DOB
Age*
Years old
Address*

Residential address

Postal Address (if different to residential address)

Town/SuburbState

Post Code
Phone Number*
Please enter a valid phone number.
Secondary Phone Number
Please enter a valid phone number.
Email address
example@example.com
Does the young person identify as Aboriginal & Torres Strait Islander?*
Is English the main language spoken at home?*
If no, what is the main language?
Please type language(s)
Is an interpreter required?*
Country of birth*
Does the young person have any communication or access needs?
If yes, please provide details
2. Emergency Contact details
Name*

First NameLast Name
Phone number*
Please enter a valid phone number.
Relationship to young person*
3. Referrer information
Referral source (who is making the referral)
Is referrer information the same as the emergency contact?*
If yes, please proceed to section 4.
Name

First NameLast Name
Organisation & role details

OrganisationJob title
Phone Number
Please enter a valid phone number.
Relationship to young person
Would you like to go on our mailing list to receive newsletters and surveys?*
4. Appointments
Who should be contacted to make appointments?*
Do you consent to receive pre-appointment survey and reminders via text message?*
Preferred appointment method*
5. Consent
Is the young person aged under 16?*
If yes, are the young person's parents/carers aware of the referral?
Do you consent for young person's details to be added to the headspace database?*
Is the young person aware of the referral?*
6. Reasons for referral
Main reason for referral
(Please choose 1)
AnxietySchool issuesLow mood/depressionStressSelf-harmFamily problemsLoss of appetiteBody imageRelationship issuesSocial isolationConcern about friend/family memberAssistance with work or studyAlcohol/drug usePhysical health
BullyingAngerSleep problemsLow self-esteem/self-worthPTSD or traumaGrief and lossSuicidal thoughts/behavioursHallucinations or delusionsHarm to othersDomestic/family violenceEmotional abusePhysical abuseSexual abuseOther
Other presenting issues

(Choose as many that apply)
AnxietySchool issuesLow mood/depressionStressSelf-harmFamily problemsLoss of appetiteBody imageRelationship issuesSocial isolationConcern about friend/family memberAssistance with work or studyAlcohol/drug usePhysical health
BullyingAngerSleep problemsLow self-esteem/self-worthPTSD or traumaGrief and lossSuicidal thoughts/behavioursHallucinations or delusionsHarm to othersDomestic/family violenceEmotional abusePhysical abuseSexual abuseOther
Please add any information to support this
How long has this been going on?
How has it been impacting the young person's daily life and for how long?
Has the young person received any mental health support before? Please specify.
7. Risk
Suicide*

NoCurrent thoughtsCurrent planCurrent intentPrevious thoughts/attempt(s)Unknown
Please add any details
Self-harm*

NoPastCurrentUnknown
Please add any details
Harm to others*

NoYesUnknown
PastCurrent
Please add any details
Additional information

Please only fill out this section if you would like to access physical health services from headspace (GP/Nurse)
GP/Medical clinic
Mental Health Treatment Plan
Medicare Card number
We need this for some physical health services
Reference number
The number next to your name
Medicare Card expiry date
Do you have a Health Care Card?
Health Care Card CRN
Customer Reference Number
Health Care Card expiry
DVA File number
DVA Card colour

GoldWhite
Please add anything else that is appropriate to support the referral to headspace
Please add any supporting documentation (previous psychiatry reports, referrals, mental health treatment plans etc.)

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Thank you for completing the referral form. Our duty worker will be in contact with the nominated person to book an appointment within 2-3 business days.

Please contact headspace on 8725 0443 or at headspacemgadmin@unitingcommunities.org if you have any questions about this submisson or to provide further information.

*please note, when our duty workers calls you to book an appointment, it will be from an Adelaide number.

Press submit when you are completed and you will be directed to our website :)
Should be Empty:

headspace Mount Gambier Referral Form

1. Young Persons details:

2. Emergency Contact details

3. Referrer information

4. Appointments

5. Consent

6. Reasons for referral

7. Risk

Additional information