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  • Self-Referral Form - Under 16 Years

    Self-Referral Form - Under 16 Years

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  • 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.

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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 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?
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  • Medical Details (if known)

  • Are you referring yourself?*
  • 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?*
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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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  • 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 your day to day or social activities?*
  • 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?*
  • Do you receive support from other services (eg: psychologist, CAMHS, AMHS)*
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  • Last questions.... almost there!

  • Do you self-harm?*
  • Are you thinking about suicide?*

  • 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.

  • 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

  • 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.

  • Format: (000) 000-0000.

  • Please tick to confirm that you understand consent, confidentiality your rights & responsibilities and consent to seeking support from headspace Hamilton.

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  • 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

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