• self referral

    it may be yourself, a friend or a family member aged 12-25 years old
  • NOTE: Professional referrers (teacher, GP, case worker, etc.) please use the professional referral form – thanks!

  • young person's details

  •  /  / Pick a Date
  • indigenous artwork - golden yellow in colour to break up young person details from emergency contact details section
  • emergency contact details

    please note your emergency contact must be at least 18 years of age
  • indigenous artwork - dark blue in colour to break up emergency contact details from reason for contact section
  • reason for contacting headspace Ballarat

    Please tell us what are the main issues that bring you to headspace Ballarat?
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  • last questions...nearly there!

  • Your privacy is important to us.

    This info will be kept confidential and used only to give you the best care possible. 

    headspace privacy policy

  • indigenous artwork - maroon in colour to break up young person details from resaon for contact and confidentiality sections
  • Consent, Confidentiality, Your Rights & Responsibilities

  • 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 unders tand 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.

    Consent to transfer information will allow:

    • Access to client assessment information only by agreed relevant other services
    • This service provider to indicate their involvement to other services
    • Case management and care co-ordination meeting discussion for care planning
    • Collection of non-identifiable statistical information

    Agreed relevant other services:

    • GP/Hospital
    • Ballarat Community Health/Mental Health Services
    • Department of Health & Human Services (e.g. CPU, Medicare, Centrelink)
    • Counselling/Welfare support services
    • Centacare Ballarat
    • The Police
    • School/School Wellbeing

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    Click the link below to read further important information about confidentiality and your rights and responsibilities when accessing headspace Ballarat services.

    Confidentiality Statement - Rights & Responsibilities 

  • If you are under 16 years of age, please list the name of the person that headspace Ballarat should contact to obtain parental/guardian consent

  • 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 sameas my normal pen and paper signature

  • Clear
  • 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 sameas my normal pen and paper signature

  • Clear
  • headspace National Youth Mental Health Foundation is funded by the
    Australian Government Department of Health.

    headspace Ballarat
    28 Camp Street BALLARAT CENTRAL VIC 3350
    Phone: 5304 4777
    Email:
    info@headspaceballarat.org.au

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