Self-Referral Form - Under 16 Years

Self-Referral Form - Under 16 Years
This referral form is for anyone under the age of 16 who wishes to seek headspace support. This may be filled in by yourself, a friend, or a family member.

NOTE: Are you a professional working with young people? (e.g. teacher, case worker, program provider) please use the professional referral form - thanks!

__________________________________________________________________

About headspace:

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

We acknowledge there are many things that can contribute to someone's mental health. That's why headspace supports young people with their:
- mental health and wellbeing
- physical and sexual health
- alcohol and other drugs support
- work, school and study
You're welcome to bring a friend or family member with you to your appointment.
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 you 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
Are you referring yourself?*

YesNo
If you answered NO to the previous question, and you’re completing this referral on behalf of a young person, is the young person aware of and consenting to the 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:*
Reason for contacting headspace Hamilton:

Select relevant issues and provide as much information as possible
Greatest Concern(s): Please feel free to list below*
Are there any general health or physical health conditions limiting your day to day or social activities?*

YesNo
If yes, please specify
Are drugs and/or alcohol having a negative impact on any areas of your health or lifestyle?*

YesNo
Do you require support with education, training and/or employment?*

YesNo
Other information you would like us to know?
Do you receive support from other services (eg: psychologist, CAMHS, AMHS)*

YesNo
If yes, please specify:
Last questions.... almost there!
Do you self-harm?*

YesNo
Are you thinking about suicide?*

YesNo
If YES, please contact South West Healthcare Mental Health Services on 1800 808 284 who can provide you with 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
Consent, Confidentiality, Your Rights & Responsibilities:

It’s also important to us that you understand what happens to your information. Please read the below information and attached documents 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 understand why my information must be collected. I also know Brophy 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 regulation. 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 coordination meeting discussion for care planning.
- Collection of non-identifiable statistical information.
Agreed relevant other sources:
- GP / Hospital
- South West Healthcare Mental Health Services
- Department of Health & Human Services (eg. Child Protection Unit, Medicare, Centrelink)
- Counselling / Welfare Support Services
- Centacare
- The Police
- School / School Wellbeing
Specific services NOT agreed to (please list):
As this form is for someone under 16, please list the name of the person that headspace Hamilton should contact to obtain parental/guardian consent.
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Relationship:*
Example: parent, legal guardian etc.
Please tick to confirm that you understand consent, confidentiality your rights & responsibilities and consent to seeking support from headspace Hamilton.
Please select 'Yes' to accept statement above

Yes
Thank you for taking the time to complete this form.

One of our headspace team members will be in contact as soon as possible and during our 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 you need 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:

Self-Referral Form - Under 16 Years

Young Person's Details

Medical Details (if known)

Emergency Contact

Reason for contacting headspace Hamilton:

Last questions.... almost there!