headspace Ballarat DBT group Expression of Interest Logo

  • DBT Group

    Expression of Interest

  • Please note this referral form is for
    Dialectical Behavioural Therapy (DBT) group only.

    This program is being offered to young people aged 14-18 years old.

    Are you seeking to book an appointment for your young person at headspace Ballarat? 

    If so, please complete this Young Person Referral Form 
    or scan the QR below

    headspace is not a crisis service or an acute mental health service.

    For acute care needs, please contact
    Grampians Area Mental Health on 1300 247 647.

    For emergency mental health support or in crisis situations, call 000. 

     

  • The DBT group is a 6-week program for adolescents (aged 14-18) which goes through skills in each of the following areas: mindfulness, distress tolerance, emotional regulation, interpersonal effectiveness, and walking the middle path. Participation is required for all 6 weeks.

    The Walking the Middle Path session is based on skills to help communication between parents and adolescents. For the Walking the Middle Path module a parent or carer will be required to attend the session.

    This is not a group therapy session, rather a group where you will learn skills in the above-mentioned areas.

    Upon receiving the referral, one of the group facilitators will be in touch with you to discuss further and get you registered for the group. Please note, you will need to speak to a facilitator before attending – completing the referral form alone does not register you for the group. The facilitator will ask additional questions, including questions regarding risk.

  • Young person details

  •  - -

  • Referrer Details

  • Contact Details of parent/carer to be attending session 4

    Carers must be 18 years or older

  • Emergency Contact Details

    Emergency Contacts must be 18 years or older

  • Privacy, Consent and Confidentiality

    Privacy is important to us at headspace Ballarat. This information will be kept confidential and used only to give the young person the best care possible.

  • headspace Privacy Policy

  • It’s also important to us that you understand what happens to your information.  Please read the below information and attached document 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 unders tand why my information must be collected. I also know headspace Ballarat 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 regulations. 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 co-ordination meeting discussion for care planning
    • Collection of non-identifiable statistical information

    Agreed relevant other services:

    • GP/Hospital
    • Ballarat Community Health/Mental Health Services
    • Department of Health & Human Services (e.g. CPU, Medicare, Centrelink)
    • Counselling/Welfare support services
    • Centacare Ballarat
    • The Police
    • School/School Wellbeing

  • Click the link below to read further important information about confidentiality and your rights and responsibilities when accessing headspace Ballarat services.

    Confidentiality Statement - Rights & Responsibilities 

     

  •  

      If you are under 16 years of age, please list below the name of the person that headspace Ballarat should contact to obtain parental/guardian consent

     

     

  • Parent, legal guardian signature: Please note that by the notation of my name in the following section, this is an electronic representation of my signature for all the purposes required in this document, just the sameas my normal pen and paper signature

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  • Young person signature: Please note that by the notation of my name in the following section, this is an electronic representation of my signature for all the purposes required in this document, just the sameas my normal pen and paper signature

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  • Thank you for taking the time to complete this referral.

    Click the Submit button below to complete.

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