• headspace Ballarat EMHSIS referral

    headspace Ballarat EMHSIS referral

    NOTE: use this form if you are school based professional

  • headspace provides free services for people aged 12 - 25,
    supporting young people with their mental health, physical health, alcohol & other drug support and work & study support. 

    headspace is not a crisis service or an acute mental health service.

    For acute care needs, please contact
    Grampians Area Mental Health on 1300 247 647.

    For emergency mental health support or in crisis situations, call 000. 

  • Referrer Details

    Enter your details here.
    Referrer Details
  • Does the young person consent for feedback to be given to the referrer?*

  • Student Details

  • Do they identify as Aboriginal or Torres Strait Islander?*
  • Are they connected to BADAC (Ballarat and District Aboriginal Co-operative)?*
  • Is an Interpreter required?*
  • Contact preference*
  • If phone call was selected as the preferred contact method, is it ok if headspace Ballarat send them appointment reminders and other information via SMS?*
  • Can headspace staff leave a voice message?*
  • Does the young person have literacy issues?*
  • Has the young person agreed to this referral?*
  • If under 16, is their parent or carer agreeable to this referral?*

  • Please note that it will not be possible to proceed with a referral to his initiative unless either parental consent has been obtained or, student consent for those deemed to be a mature minor.

  • Emergency Contact's Details

    Emergency contacts must be 18 years or older.

  • Reason for contacting headspace Ballarat

    Select the relevant issues and provide as much information as possible
    Reason for contacting headspace Ballarat
  • Other presenting issues

  • Current | Past Support Services

  • Does the young person have a metnal health treatment plan from a GP?*

  • Risk

  • Self-harm?*
  • Suicide?*
  • You have selected Yes, the young person is currently having suicidal thoughts, do they have a plan or intent?*

  • For young people experiencing current suicidal thoughts with a plan or intent,  headspace Ballarat is unable to provide the level of support required.

    Call Grampians Area Metal Health on 1300 247 647 or, for emergency mental health support in a crisis situation, call 000. 

  • Privacy, Consent and Confidentiality

    Privacy is important to us at headspace Ballarat. This information will be kept confidential and used only to give you the best care possible.

  • headspace Ballarat Privacy Policy

  • Upload a document

    E.g. mental health care plan, safety plan, risk management plan, discharge summary
  • Browse Files
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    Choose a file
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  • Client Consent Form

    Please share the below link with the student you are referring, ask them to review and submit the form. You can copy and paste the link into an email or, send via SMS. A student’s parent or legal guardian will also need to sign this form unless they are deemed to be a mature minor : https://form.jotform.com/headspaceballarat/client-consentPlease note that we are unable to contact or meet with any students referred for EMHSIS until written consent hasbeen obtained. This is a requirement of the Department of Education.

  • Please share the below link with the student you are referring, ask them to review and submit the form.  You can copy and paste the link into an email or, send via SMS.

    https://form.jotform.com/headspaceballarat/EMHSIS-Consent

    A student’s parent or legal guardian will also need to sign this form unless the student is deemed to be a mature minor.

    Please note that we are unable to contact or meet with any students referred for EMHSIS until written consent hasbeen obtained. This is a requirement of the Department of Education.

  • https://form.jotform.com/headspaceballarat/EMHSIS-Consent

  • Thank you

    Click the Submit button below right.
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