headspace Echuca | 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.
The young person can get support for their mental health by creating a headspace account at headspace.org.au, or they can peak to someone 1-on-1 via chat, email, or over the phone at eheadspace.org.au or 1800 650 890

If they are in immediate risk, please contact Bendigo Psychiatric Triage on 1300 363 788, this number is contactable 24 hours a day, 7 days a week or call 000.

headspace Echuca is not a crisis service.

If the young person needs to speak to someone urgently:

Lifeline 13 11 14

Kids Helpline 1800 551 800

Suicide Call Back Service 1300 659 467

PLEASE NOTE: HEADSPACE SERVICES ARE FOR YOUNG PEOPLE BETWEEN THE AGES OF 12-25
Young Persons Details
Has the young person consented to this referral?*

YesNo
If your young person does not consent to this referral please call us on 5485 5048
Legal Full name*

First NameLast Name
Do they have a preferred name (if different from legal name)?*

YesNo
If yes, what is their Preferred Name (optional)

First NameLast Name
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.
Gender*

MaleFemalePrefer not to sayOther
What is the young person's sexual orientation?*

Straight/ HeterosexualLesbianGayBisexualOther sexualityQuestioningI don't know what these words meanChoose not to answerUnknown
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
Does the young person have a GP provider?*

YesNo
If you answered yes please provide details below:
Name of GP provider
Name of GP practice
Contact phone number
If under 16 are their parents/carers aware of this referral?*

YesN/ANo
Parent/carer name*
Parent/carer phone number*
Have they received services from headspace Echuca in the past?*

YesNo
Who should headspace contact to make an appointment?*

Young person (if aged 16 or more)ReferrerParent/carer
Is this a referral for the young person to receive services online via our VideoCall/Telephone service?

YesNo
Referrers details
Name of person submitting this referral*

First NameLast Name
Email*
example@example.com
Phone number*
Your relationship to the young person*
Service/ Agency if applicable*
Current/past support services
Does the young person or did they ever receive support from other services?*

YesNoNot sure
Name or description of other services
eg. Youth Mental Health Team, CAMHS, Bendigo Mental Health Team, Centre Against Sexual Assault (CASA), Anglicare, Haven, Youth Justice ect.
Has the young person received assistance from other mental health services prior to this referral?*

YesNoUnsure
Emergency contact

*Please note* if the young person is under 18 we will contact the emergency contact if we cannot contact them.
Full Name*

First NameLast Name
Relationship to young person *
Phone number*
Email*
example@example.com
If the young person is over 18, do they give us permission to contact this person if we cannot contact them?

YesNo
What is your reason for referring the young person to headspace Echuca?

Please select the options below that match the young person's situation.
Please describe *

Physical healthFamily issuesAnxiety stressLow moodSexual healthTrauma/griefAccommodationAlcohol and drugsSelf harmThinking of suicideRelationship issuesEmployment issuesFriendship issuesSchool issues
Other:
Please describe
Additional comments

Is there anything else you think we should know about? Tell us more here.
Please provide a summary of your key concerns to help us better support the young person or their family:*
Upload any relevant supporting documents (shared support plan, relevant assessments, mental health care plan etc)

Upload a File

Cancelof
How did you find out about headspace Echuca?*

School presentationSchool wellbeing teamCommunity eventSocial mediaFriends or familyOther
Privacy

Privacy is important to us. This information will be kept confidential and used only to give you the best care possible. https://headspace.org.au/eheadspace-privacy-policy/
I have read and I understand this privacy information*

YesNo
Check before submitting:*

Young person is aged between 12 -25Young person consents to this referralGuardian consents to the referral (under 16)
Please note: Referrals will be acknowledged to within 2 working days. If you have not recieved a referral acknowledgement, please call us on 5485 5048.
Should be Empty:

Family, Friend or Professional Referral Form

Young Persons Details

Referrers details

Current/past support services

Emergency contact

What is your reason for referring the young person to headspace Echuca?

Additional comments

Privacy