AOD Single Session Support

AOD Single Session Support

Application Form
The headspace Ballarat AOD Single Session Support (SSS)
is provided in partnership with Uniting Vic Tas.

This service is for non-crisis, confidential alcohol and other drug counselling.
This service is free of charge and available to young people aged 12-25 years.

If you need urgent AOD support, please contact one of these services:

Directline
24 Hours 7 Days - Free And Confidential support
for young people, famly and carers
Phone: 1800 888 236

YoDAA
Monday - Friday from 9am - 5pm
Youth Drug and Alcohol Advice for young people, family and carers
Phone: 1800 458 685

Continue with this form to register for AOD Single Session Support at
headspace Ballarat
Level 1, 20 Dawson Street North, BALLARAT CENTRAL
Who is completing this application form?
Referrer details
Name of referrer

First NameLast Name
Referrer Organisation
Referrer Role
Referrer Phone Number
Referrer Email
Young Person's details
Young Person Name

First NameLast Name
Preferred Name

First NameLast Name
Date of Birth

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
Age
Single Session Support is available to young people aged 12 - 25 years
Gender
Pronouns
Is the young person experiencing homelessness?
Phone Number
Can we SMS this phone number?
Email
Address

Street Address

Street Address Line 2

City/TownState

Postcode
What is your primary drug of concern?
Please include any other information you wish to share here:
Emergency Contact
Emergency contact name

First NameLast Name
Relationship
Their phone number
Client Consent
For professional referrrals to the AOD Single Session Support program,
headspace will contact the young person and, if relevant, their parent/legal guaridan to obtain client consent.
Privacy is important to us. Your information will be kept
confidential and used only to give you the best care possible.

headspace Privacy Policy

It’s also important to us that you understand what happens to your information. Please read the below information and attached document carefully and, if you have any questions, ask us!

I have read the information for the collection and use of my personal information document and understand why my information must be collected.

I also know headspace Ballarat has a Privacy Policy, which covers the collection, storage, disclosure, and security of client information.

The Policy conforms to the Health Records and Information Privacy Act 2002 and all other relevant Government laws and regulations.

I understand that I do not have to give information when asked, but not doing so may limit the range of services available to me.
I (the young person) have read and understand this Privacy information
I (the young person) understand, in order for headspace Ballarat to provide Single Session Support, that an Electronic Medical Record will be created.
Young person signature: Please note that by the notation of my name in the following section, this is an electronic representation of my signature for all the purposes required in this document, just the same as my normal pen and paper signature
Signature
Parent or legal guardian consent

I consent to my young person accessing AOD Single Session Support
Name of Parent/legal guardian

First NameLast Name
Relationship
Their phone number
Parent / Legal guardian signature: Please note that by the notation of my name in the following section, this is an electronic representation of my signature for all the purposes required in this document, just the same as my normal pen and paper signature
Signature
Should be Empty:

AOD Single Session Support

Referrer details

Young Person's details

Emergency Contact

Client Consent

Parent or legal guardian consent