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  • Professional's Referral

    Professional's Referral

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  • 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.

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  • Young Person's Details

  • Are you Aboriginal or Torres Strait Islander?*
  • Are you connected to any local Aboriginal Co-operatives?*
  • Interpreter Required?*
  • Date of Birth*
     / /
  • Format: (000) 000-0000.
  • Contact Preference?*
  • 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?
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  • Medical Details (if known)

  • Has the young person agreed to this referral?*
  • Does the young person have literacy issues?
  • If under 16, is their parent or carer aware of this referral?*
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  • Emergency Contact

    Please note that the emergency contact must be at least 18 years of age.
  • Format: (000) 000-0000.
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  • Referrer Details:

  • Format: (000) 000-0000.
  • Will you/your service stay connected with the young person?*
  • Does the young person consent for feedback to be given to the referrer?*
  • Who should headspace Hamilton contact to make an appointment?*
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  • 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?*
  • Is the young person currently experiencing mental ill health?*
  • Are drugs and/or alcohol having a negative impact on any areas of your health or lifestyle?*
  • Do you require support with education, training and/or employment?*
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  • Current / Past Support Services:

  • Does the young person receive support from other services*
  • Has the young person received assistance from other mental health services prior to this referral?*
  • Does the young person self-harm?*
  • Is the young person thinking about suicide?*

  • 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.

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  • 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

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