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*
Are you Aboriginal or Torres Strait Islander?*

AboriginalTorres Strait IslanderBoth Aboriginal and Torres Strait islanderNeither 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*
Phone*
Contact Preference?*

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

YesNo
Email*
example@example.com
Medical 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 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*
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 Hamilton contact to make an appointment?*

Young PersonReferrerParent / Carer
Reason for contacting headspace Hamilton:

Select relevant issues and provide as much information as possible
Are there any general health or physical health conditions limiting 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 your 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 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
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 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: