Young Person Self Referral

If you are a Young Person (aged 12-25) referring yourself, please use this Form

If you are a Family or Friend referring a Young Person on their behalf, please use

If you are a Professional Referrer (e.g Teacher, GP, Case Worker etc), please use

Please note; headspace Mildura is not an acute mental health/crisis service. If you have immediate concerns regarding your safety/wellbeing, please contact Emergency Services on 000 or Mildura Base Public Hospital Mental Health Services on (03) 5022 3500

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Contact Information

Name:*

First NameLast Name

Preferred Name:

Is your preferred name known by your Emergency Contact?

Yes; it is safe to useNo; please do not use

If you have been previously known by another name, please provide details:

Pronouns:

If other, please specify:

Gender:

Age:*

Date of Birth:*

Date

Phone Number:*

Email:

example@example.com

Residential Address:*

Street Address

Street Address Line 2

SuburbState

Post Code

Postal Address (if different to above):

Street Address

Street Address Line 2

SuburbState

Post Code

Are you of Aboriginal or Torres Strait Islander origin?

What is your main cultural background other than Australian or Aboriginal and Torres Strait Islander?

Country of Birth:

Main language other than English spoken at home:

Do you require an interpreter?*

YesNo

If yes, please provide language required:

Are you enrolled in school or employed?

YesNoOther

If yes, please provide name of school/workplace:

Please provide details of any current supports/services in place (i.e. School Wellbeing, GP, Psychologist):

Medicare Number:

*required for physical/sexual health clinic

Medicare Reference Number:

*required for physical/sexual health clinic

Medicare Expiry Date:

*required for physical/sexual health clinic

Do you have an NDIS Package:

YesNoUnknown

Medications/Medical history (if any):

Allergies (if any):

Are your parents/guardians aware of this referral?*

YesNo

Do you give permission for your parents/guardians to be involved in your support at headspace?*

YesNo

If yes, please provide their details:

Emergency Contact
This is required if you are under the age of 16 years

Name:

*Must be over the age of 18 years

Relationship:

Phone Number:

Reasons for contacting headspace Mildura

Reason 1*

Reason 1 information*

Reason 2*

Reason 2 information*

Reason 3

Reason 3 information

Reason 4

Reason 4 information

Reason 5

Reason 5 information

Other information:

Do you have thoughts of self harm or suicide?*

NoYes - self harmYes - suicide

Do you self harm?*

NoYes

Are you currently at risk of suicide?*

NoYes

Who would you like us to first contact to discuss your referral further?*

If other, please provide their details:

Who would you like to receive the SMS appointment reminder?

If other, please provide their details:

Thank you for your referral. A team member will be in touch with yourself or your nominated contact within the next 3 business days.

Please note; headspace Mildura is not an acute mental health/crisis service. If you have immediate concerns regarding your safety/wellbeing, please contact Emergency Services on 000 or Mildura Base Public Hospital Mental Health Services on (03) 5022 3500

Your privacy is important to us. To provide the best care, the information provided will be used to create a headspace profile and electronic medical record. Records will be kept confidential and your consent will be required to share any information. Please refer to our privacy policy and speak with a staff member if you have any questions or concerns:

headspace Privacy Policy

I have read and understood the privacy information*

YesNo