• Physical Health Registration Form

    Complete this form to have your electronic medical record (EMR) created or updated

  • Your name, age, culture and ethnicity

  • Date of birth*
     - -
  • Do you identify as First Nations?*

  • Your contact details

  • Does this phone number belong to you?*
  • Can we send SMS such as Appointment Reminders and Recalls to this number?*
  • Do you want to add a secondary contact phone number?*

  • Emergency Contact Details

  • My emergency contact is:

  • Medicare and Health Care Concession Cards

  • Do you have a Medicare Card?*
  • Is the name on your Medicare card different to your preferred name above?
  • Do you have a Health Care Concession Card?*

  • What brings you to headspace?

    Select all that apply.
  • I would like more information or support with:

  • Confidentiality and Consent

  • Consent, Confidentiality, Your Rights & Responsibilties


    Privacy is important to us at headspace Ballarat. Your information will be kept confidential and used only to give you 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 understand 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
    • The Police
    • School Wellbeing

  • Consent

    For young people under 16 years of age, parent or legal guardian consent is required to access services at headspace Ballarat.

  • 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 same as my normal pen and paper signature

  • 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 same as my normal pen and paper signature

  • Should be Empty: