headspace Swan Hill | Family, Friend or Professional referral form

Family, Friend or Professional Referral Form

Use this form if you are a family member, friend or GP/support worker/teacher etc.
About the young person
Has the young person agreed to this referral?*

YesNo
Full name*

First NameLast Name
Are they known by any other names?*

YesNo
Date of birth*

DayMonthYear
Address*

Street Address

Street Address Line 2

City/townState

Postcode
Young person's phone number*
Young person's e-mail
If the young person is currently enrolled in secondary school please state which one*
Name of Secondary School if applicable.
Is this a referral for the young person to receive services online via our VideoCall/Telephone service?

YesNo
Gender*

MaleFemaleOther
What are their preferred pronouns?

Him/hisShe/herThey/themPrefer not to answer
Is the young person Aboriginal or Torres Strait Islander?*

NoAboriginalAboriginal and Torres Strait IslanderTorres Strait IslanderPrefer not to say
Country of birth
Preferred language
Interpreter required? *

YesNo
Does the young person have literacy issues?

YesNo
Medicare number
Medicare reference number
Medicare expiry date

DayMonthYear
Does the young person have a Health Care Card?

YesNo
Customer Reference Number (CRN)
Health Care Card expiry date

DayMonthYear
If under 16 are their parents/carers aware of this referral?*

YesN/ANo
Parent/carer name*
Parent/carer phone number*
Relationship to the young person*
Referrer details
Who should headspace Swan Hill contact to make an appointment?*

Young person (if aged 16 or more)ReferrerParent/carer
Referrers name*

First NameLast Name
Phone number*
Email*
Service if applicable*
Your relationship to the young person*
Current/past support services
Does the young person receive support from other services?*

YesNoNot sure
Name or description of other services
Name or description of other services
Has the young person received assistance from other mental health services prior to this referral?*

YesNoUnsure
Do they have a doctor?*

YesNoNot sure
Doctor/ Clinic Name
Doctor/clinic contact phone number
Emergency contact
Full Name*

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

Please select the options below that match the young person's situation.
Physical healthFamily issuesAnxiety stressLow moodSexual healthTrauma/griefAccommodationAlcohol and drugsSelf harmThinking of suicideRelationship issuesEmployment issuesFriendship issuesSchool issuesOther
Please indicate the young person's preferred clinician gender (if any)*

No preferenceFemaleMale
Additional comments

Is there anything else you think we should know about? Tell us more here.
Privacy
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
Upload any relevant supporting documents (shared support plan, relevant assessments, mental health care plan etc)

Upload a File

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Family, Friend or Professional Referral Form

About the young person

Referrer details

Current/past support services

Emergency contact

Reason for contacting headspace Swan Hill

Additional comments

Privacy