headspace Swan Hill | Self referral form

For you to fill out. You can do it with the help of a family member or friend if needed...no worries.

Good on you for making it this far. This form won't take you very long. Some areas below are marked with a red asterisk and are essential to fill out. It is up to you whether you want to fill out the others.
Are you referring yourself?*

YesNo
Family, Friends and Professional referrers (GP, teacher, case worker etc.)... please use our 'Family, Friend or Professional Referral Form' https://form.jotform.co/headspaceSH/family-friend-professional-form.
Full Name*

First NameLast Name
Date of birth*

DayMonthYear
Gender*

MaleFemaleOther
What are your preferred pronouns?

Him/hisShe/herThey/themPrefer not to answer
Address*

Street Address

Street Address Line 2

City/townState

Postcode
Phone number *
E-mail*
Would you like to receive support online via our VideoCall service or by telephone?

YesNo
Do you identify as Aboriginal or Torres Strait Islander?*

NoAboriginalAboriginal and Torres Strait IslanderTorres Strait IslanderPrefer not to say
If under 16 are your parents/carers aware of this referral?*

YesNoNA
Country of birth/ethnicity?
Preferred language
Do you need an interpreter?

YesNo
If you are still in school, which one?
Is there a family member or worker you would like us to speak to?

YesNo
Contact phone number
Name of family member or worker
Do you have a Doctor?

YesNo
Doctor/ Clinic Name?
Doctor/ Clinic contact phone number
Medicare Card number
Medicare Card reference number
Medicare Card expiry date
Emergency contact
Full Name*

First NameLast Name
Phone number *
Relationship to you*
Reason for contacting headspace Swan Hill

Please select the options below that match your situation.
*

I'd like someone to talk toThings just aren't going very wellEmployment issuesSchool issuesFriendship issuesRelationship issuesPhysical healthFamily issuesAnxiety stressLow moodSexual healthTrauma/griefI need a mentor/coachAlcohol and other drugsHousing SupportSelf harmThinking of suicideI'm concerned about someone close to meOther
Please indicate your preferred clinician gender (if any)*

No preferenceFemaleMale
Additional comments

Tell us more here. Is there anything else you think we should know about?
Your privacy is important to us. This information will be kept confidential and used only to give you the best care possible.

headspace privacy policy
I have read and I understand this privacy information*

YesNo
Should be Empty:

For you to fill out. You can do it with the help of a family member or friend if needed...no worries.

Emergency contact

Reason for contacting headspace Swan Hill

Additional comments