Self-Referral Form

Self-Referral Form

headspace Ballarat
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 acute care needs, please contact
Grampians Area Mental Health on 1300 247 647.

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

Ensure all sections in the form below are completed,
and please contact headspace Ballarat if you have any questions about how to complete this form. Completing the form may take up to 10 minutes.

28 Camp Street Ballarat Central

Phone: 03 5304 4777

Email: info@headspaceballarat.org.au

Young person details
Given Name*

First NameLast Name
Preferred Name

First NameLast Name
Gender*
Pronouns
Country of Birth & Ethnicity*
Do you identify as First Nations?*

AboriginalTorres Strait IslanderAboriginal and Torres Strait IslanderNeither Aboriginal nor Torres Strait Islander
Are you connected to BADAC (Ballarat and District Aboriginal Co-operative)?*

YesNoUnknown to referrer
Preferred language*
Is an interpreter required?*

YesNo
Do you have any communication or access needs?*

YesNo
If yes, please provide details
Date of Birth*

DayMonthYear
Date
Age*
years old
Address*

Residential/Street Address

Postal Address (if different to residential address)

Town/SuburbState

Post Code
Phone Number*
This phone number belongs to the person being referred*

YesNo
Preferred contact method*

SMSPhone call
Can headspace leave a voice message*

YesNo
If phone call was selected as the preferred contact method, is it ok if headspace Ballarat send appointment reminders and other information via SMS?*

YesNo
Email
Primary contact person
Who is the best person for headspace Ballarat to contact initially about this referral and about appointment options? It may be the young person referred, a friend, a carer or a family member.*

Young personAnother person
Name of Primary Contact*

First NameLast Name
Their Relationship to you*
E.g. Parent, Kinship Carer
Their Phone Number*
If you are under 16, is your parent or legal guardian aware of this referral?*

YesNo
Medicare Card Number
10 digits
Medicare Reference Number
Medicare Card Expiry Date
MM/YY
Emergency Contact Details

Emergency contacts must be 18 years or older
Name*

First NameLast Name
Emergency Contact Phone*
Their Relationship to Young Person*
E.g. Parent, Kinship Carer
Reasons for contacting headspace Ballarat

Please provide as much information as possible
Main reason for referral*

AnxietySchool issuesLow mood/depressionStressSelf-harmFamily problemsRelationship issuesSocial isolationConcerns relating to friend/family membersSupport with work and studyLoss of appetiteBody image concernsLow self esteem/self-worthPhysical healthSleep problemsPTSD or traumaGrief and lossHallucinations or delusionsAlcohol/drug useSuicidal thoughts/behavioursHarm to othersDomestic/family violenceEmotional abusePhysical abuseSexual abuseBullyingAngerOther
Please tell us what is the main reason for contacting headspace Ballarat*
What other issues would you like support with?

AnxietySchool issuesLow mood/depressionStressSelf-harmFamily problemsRelationship issuesSocial isolationConcerns relating to friend/family membersSupport with work and studyLoss of appetiteBody image concernsLow self esteem/self-worthPhysical healthSleep problemsPTSD or traumaGrief and lossHallucinations or delusionsAlcohol/drug useSuicidal thoughts/behavioursHarm to othersDomestic/family violenceEmotional abusePhysical abuseSexual abuseBullyingAngerOther
Please provide additional information relating to the presenting concerns selected
How long has this been going on?
How has it been impacting your health or lifestyle?
Have you received any mental health support before? If yes, please provide details
Do you have a mental health treatment plan from a GP*

YesNoUnknown
Are you enrolled in school or further study?

Primary SchoolSecondary SchoolTAFEUniversityOtherNoPrefer not to say
If you answered Secondary School, please select where you are enrolled
If you answered University, please select where you are enrolled
Risk
Do you self-harm?*

No, neverNot currently, but I have in the pastYes, currently
Are you thinking about suicide?*

No, I have never experienced suicidal ideationYes, I have current thoughtsNot now but previously I have had thoughts/attempts
You have selected Yes, I have current thoughts, do you have a plan or intent?*

No, I have neither a plan nor intentYes, I have a current planYes, I have current intent
For young people experiencing current suicidal thoughts with a plan or intent, headspace Ballarat is unable to provide the level of support required.

Call Grampians Area Metal Health on 1300 247 647 or, for emergency mental health support in a crisis situation, call 000.
Harm to others*

Not applicablePastCurrentUnknown
You can provide further information relating to self-harm, suicide and concerns relating to harm to others here:
Consent, Confidentiality, Your Rights & Responsibilties

Privacy is important to us at headspace Ballarat. Your information will be kept confidential and used only to give you the best care possible.
headspace Privacy Policy
I have read and understand this Privacy information*

Yes
It’s also important to us that you understand what happens to your information. Please read the below information and attached document 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 unders tand why my information must be collected. I also know headspace Ballarat 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 regulations. 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 co-ordination meeting discussion for care planning
- Collection of non-identifiable statistical information
Agreed relevant other services:
- GP/Hospital
- Ballarat Community Health/Mental Health Services
- Department of Health & Human Services (e.g. CPU, Medicare, Centrelink)
- Counselling/Welfare support services
- Centacare Ballarat
- The Police
- School/School Wellbeing
Specific services NOT agreed to (please list):
Click the link below to read further important information about confidentiality and your rights and responsibilities when accessing headspace Ballarat services.

Confidentiality Statement - Rights & Responsibilities
If you are under 16 years of age, please list below the name of the person that headspace Ballarat should contact to obtain parental/guardian consent
Name*

First NameLast Name
Their phone number:*
Their relationship to you:*
Parent, legal guardian signature: Please note that by the notation of my name in the following section, this is an electronic representation of my signature for all the purposes required in this document, just the sameas my normal pen and paper signature
Signature of parent/legal guardian*

Clear
Young person signature: Please note that by the notation of my name in the following section, this is an electronic representation of my signature for all the purposes required in this document, just the sameas my normal pen and paper signature
Signature of young person/client*

Clear
Upload a document

E.g. mental health treatment plan, safety plan, risk management plan, discharge summary
Cancelof
Thank you for taking the time to complete this referral.

Click the Submit button below to complete.
Should be Empty:

Young person details

Primary contact person

Emergency Contact Details

Reasons for contacting headspace Ballarat

Risk

Consent, Confidentiality, Your Rights & Responsibilties