Professional working with young people referral

Professional's Referral
NOTE:

Use this form if you are a professional working with young people (e.g. teacher, case worker or program provider).

If you are a GP please email a referral letter and a Mental Health Care Plan (if applicable) to headspacehamilton@brophy.org.au

__________________________________________________________________

About headspace:

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

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

NameSurname
Preferred name*
Pronouns*
Gender (For example: male, female, trans, intersex, nonbinary, other):*
Country of Birth & Ethnicity*
AboriginalTorres Strait IslanderBoth Aboriginal and Torres Strait islanderNeither Aboriginal nor Torres Strait Islander
YesNo
If yes, please specify.
Preferred Language*
YesNo
Date of Birth*

MonthDayYear
Date
Young Person's Age*
Address*
Phone*
Phone CallSMS
YesNo
Email*
example@example.com
Medical Details (if known)
Medicare number 10 digits
Medicare reference number
YesNo
YesNo
YesNo
Emergency Contact

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

First nameSurname
Emergency contact phone:*
Relationship:*
Referrer Details:
Name*

First nameSurname
Service & Position/Role*
Contact Phone Number*
YesNo
YesNo
Young PersonReferrerParent / Carer
Reason for contacting headspace Hamilton:

Select relevant issues and provide as much information as possible
YesNo
If yes, please specify
YesNo
If yes, please specify
YesNo
If yes, please specify
YesNo
Other information you would like us to know
Current / Past Support Services:
YesNo
If yes, please specify
YesNo
If yes, please specify
YesNo
YesNo
If YES, please contact South West Healthcare Mental Health Services on 1800 808 284 so they can provide urgent professional support.
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
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 this form

One of our headspace team members will attend to this matter as soon as possible during open hours.

headspace Hamilton Open Hours

Monday 9am-5pm

Tuesday 9am-5pm

Wednesday 9am-7pm*

Thursday 9am-7pm*

Friday 9am-5pm

*appointment only after 5pm

If the young perosn needs immediate assistance call 000, or to speak to someone urgently phone:

Lifeline 13 11 14

South West Healthcare Mental Health Services 1800 808 284

Suicide Call Back Service 1300 659 467
Should be Empty:

Professional's Referral

Young Person's Details

Medical Details (if known)

Emergency Contact

Referrer Details:

Reason for contacting headspace Hamilton:

Current / Past Support Services: