Self-Referral

Self-Referral

Over 16 Years Form (16-25 years old)
This referral form is for anyone over the age of 16 who wishes to seek headspace support. This may be filled in by yourself, a friend, or a family member.

NOTE: Professional referrer (teacher, case worker, etc please use the professional referral form - thanks!

______________________________________________________________________________________________

About headspace:

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

We acknowledge that there many things can contribute to someone's mental health. That's why headspace supports young people with their:
- mental health and wellbeing
- alcohol and other drugs support
- work, school and study
You're welcome to bring a friend or family member with you to your appointment.
Young Person's Details:
Name*

First nameSurname
Preferred name*
Pronouns
Gender (For example: Male, Female, Trans, Intersex, Nonbinary, other):*
Country of Birth & Ethnicity*
Are you Aboriginal or Torres Strait Islander:*

AboriginalTorres Strait IslanderBoth (Aboriginal and Torres Strait Islander)Neither (Aboriginal nor Torres Strait Islander)
Are you connected to any local Aboriginal Co-operatives?

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

YesNo
Date of Birth:*

MonthDayYear
Date
Young Person's Age:*
Address:*
Please include: Street & Town
Phone:*
Contact Preference:*

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

YesNo
Email*
example@example.com
Medicare Details (if known):
Medicare number 10 digits
Medicare reference number
Are you referring yourself?*

YesNo
If you answered NO to the previous question, and you're completing this referral on behalf of a young person, is the young person aware of and consenting to the referral?

YesNo
Emergency Contact:

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

First nameSurname
Emergency contact phone*
Relationship*
Example: parent, legal guardian etc.
Reason for contacting headspace Portland:

Please tell us what are the main concerns that bring you to headspace Portland?
Greatest Concern(s): Please feel free to list below*
Are there any general health issues limiting your day to day or social activities?*

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

YesNo
Do you require support with education, training and/or employment?*

YesNo
Do you receive support from other services? (eg: Psychologist, CAMHS, AMHS etc.)*
If yes, please specify what other services:
Other information you would like us to know
Do you self-harm?*

YesNo
Are you thinking about suicide?*

YesNo
If YES,

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

Your 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
Consent, Confidentiality, Your Rights & Responsibilities:

It's also important to us that you understand what happens to your information. Please read the below information and attached documents carefully and, if you have any questions, ask us! I have read the information for the collection and use of my personal information document and understand why my information must be collected. I also know Brophy has a privacy policy, which covers the collection, storage, disclosure, and security of client information. The policy conforms to the Health Records and Information Privacy Act 2002 and all other relevant government laws and regulation. I understand that I do not have to give information when asked, but not doing so may limit the range of services available to me.

Consent to transfer information will allow:

Access to client assessment information only by agreed relevant other services. This service provider to indicate their involvement to other services. Case management and care coordination meeting discussion for care planning. Collection of non-identifiable statistical information.

Agreed relevant other sources:
- GP / Hospital
- South West Healthcare Mental Health Services
- Department of Health & Human Services (eg. Child Protection Unit, Medicare, Centrelink)
- Counselling / Welfare Support Services
- Centacare Warrnambool
- The Police
- School / School Wellbeing
Specific services NOT agreed to please list
As this form is for someone over 16, please sign to confirm that you understand consent, confidentiality your rights & responsibilities and consent to seeking support from headspace Portland.

Please note that by the notation of my name in the following section, this is an electronic representation of my signature for all purposes required in this document, just the same as my normal pen and paper signature.
Sign by the young person*

Clear
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:

Young Person's Details:

Medicare Details (if known):

Emergency Contact:

Reason for contacting headspace Portland: