Professional's Referral

Professional's Referral
NOTE:

Use this form if you are teacher or other professional working with young people - thanks!

_______________________________________________________________________________________________

About headspace:

headspace Portland is an early intervention mental health satellite service for young people aged 12-25 years.

As you're referring a young person to headspace, you must have permission for the referral to be made.
Young Person's Details:
Name:*

First NameLast Name
Preferred name:
Pronouns:
Gender (For example: male, female, trans, intersex, nonbinary, other):*
Country of Birth & Ethnicity:*
Is the young person Aboriginal or Torres Strait Islander:*

AboriginalTorres Strait IslanderBoth (Aboriginal & Torres Strait Islander)Neither (Aboriginal nor Torres Strait Islander)
Is the young person connected to any local Aboriginal Co-operatives?

YesNo
If yes, please specify:
Preferred Language:*
Interpreter required?

YesNo
Date of birth:*

MonthDayYear
headspace services young people aged 12-25 years
Young persons age:*
Address:*
Please include: Street & Town
Phone:*
Contact Preference:*

Phone CallSMS
If the young person selected phone call as your preferred method of contact, is it ok for headspace Portland send the young person appointment reminders and other information via SMS?*

YesNo
Email
example@example.com
Medicare Details (if known):
Medicare number 10 digits
Medicare reference number
Has the young person agreed to this referral?*

YesNo
Does the young person have literacy issues?*

YesNo
If under 16, is their parent or carer aware of this referral?*

YesNo
Emergency Contact:

Please note that your emergency contact must be at least 18 years of age.
Emergency contact name:*

First nameSurname
Emergency contact phone:*
Relationship:*
Example: parent, legal guardian etc.
Referrer details:

Enter your details here.
Name:*

First nameSurname
Service & Position/Role:*
Contact Phone Number:*
Will you/your service stay connected with the young person?*

YesNo
Does the young person consent for feedback to be given to the referrer?*

YesNo
Who should headspace Portland contact to make an appointment?*

Young PersonReferrerParent / Carer
Reason for contacting headspace Portland:

Select relevant issues and provide as much information as possible.
Are there any general health or physical health conditions limiting their day to day or social activities?*

YesNo
If yes, please specify:
Is the young person currently experiencing mental ill health?*

YesNo
If yes, please specify:
Are drugs and/or alcohol having a negative impact on any areas of their health or lifestyle?*

YesNo
If yes, please specify:
Do you require support with education, training and/or employment?*

YesNo
Other information you would like us to know:
Current / Past Support Services:
Does the young person receive support from other services?*

YesNo
If yes, please specify:
Has the young person received assistance from other mental health services prior to this referral?*

YesNo
If yes, please specify:
Does the young person self-harm?*

YesNo
Is the young person thinking about suicide?*

YesNo
If YES,

Please contact South West Healthcare Mental Health Services on 1800 808 284.

Privacy is important to us.

This information will be kept confidential and used only to give you the best care possible.
Brophy Agency Brochure - What you need to know
I have read and understand the information provided in the Brophy Agency Brochure:*

Yes
Upload any relevant supporting documents (mental health treatment plan, safety plan, risk management plan, etc):

Cancelof
Thank you for taking the time to complete.

One of our headspace Access and Early Intervention team members will attend to this matter as soon as possible.
Should be Empty:

Professional's Referral

Young Person's Details:

Medicare Details (if known):

Emergency Contact:

Referrer details:

Reason for contacting headspace Portland:

Current / Past Support Services: