Parent and Carer Peer Support - Professional Referral Form

Parent and Carer Peer Support Program Professional Referral

headspace Ballarat’s Family Carer and Peer Navigator is available to support parents, carers, and family members of young people (aged 12-25 years) with mental and physical health concerns. This could include service navigation, exploring various support options, providing information, advice, and referral options.
All fields marked with * are required and must be filled
Parent/Carer/Guardian's details
Parent/Carer Name*

First NameLast Name
Gender (male, female, trans, intersex, non-binary, other*
Preferred language
Address*

Street Address

Street Address Line 2

CityState

Post Code
Phone*
Email
Second parent/carer/guardian's contact details

(if applicable)
Second parent/carer name

First NameLast Name
Their phone number*
Young person's details
Name*

First NameLast Name
Their date of birth*

DayMonthYear
Date
Reason for contacting headspace Ballarat*

School refusalYoung person's behaviourYoung person's mental healthTech, social media and gamingRelationship supportDrug and alcohol issuesOther
Are they, the parent/carer/guardian currently linked with any other services?

YesNo
If yes, please detail other services here:
Consent and Confidentiality
Please share this link with parent/carer/guardian:

https://form.jotform.com/headspaceballarat/peer-support-consent

A referral will be unable to proceed until the consent and confidentiality form has been received.
Referrer details

Enter your details here:
Name of referrer*

First NameLast Name
Referrer's organisation or workplace*
Referrer's role / position *
what is your role or your relationship to the person being referred
headspace Ballarat

28 Camp Street BALLARAT CENTRAL VIC 3350

Phone: 5304 4777

Email: info@headspaceballarat.org.au
Should be Empty:

Parent and Carer Peer Support Program Professional Referral

Parent/Carer/Guardian's details

Second parent/carer/guardian's contact details

Young person's details

Consent and Confidentiality

Referrer details