1. headspace Ballarat - Self Referral Form

STOP! Professional referrer [teacher, GP, case worker etc]

Please use the 'professional' referral form - thanks!

Name *

First name Surname

Preferred name

Pronouns

Gender [male, female, trans, intersex, non binary, other] *

Country of Birth & Ethnicity

Are you Aboriginal or Torres Strait Islander? *

Aboriginal Torres Strait Islander Both Aboriginal and Torres Strait Islander Neither Aboriginal nor Torres Strait Islander

Are you connected to BADAC {Ballarat & District Aboriginal Co-operative}?

Yes No

Preferred Language

Interpreter required? *

Yes No

Birth Date *

Your age *

Address *

Street Address

Street Address Line 2

City/Town State

Postcode Country

Phone *

Email *

example@example.com

Contact Preference *

Phonecall SMS

headspace can send me SMS contact

Yes No

Medicare Number

Medicare Reference Number

Are you referring yourself? *

Yes No

Emergency Contact Name *

First Name Last Name

Emergency contact phone *

Relationship *

Greatest problem(s) *

Are there any general health issues limiting your day to day or social activities? *

Yes No

Please provide some details about how general health issues are impacting you... *

Are drugs and/or alcohol having a negative impact on any areas of your health or lifestyle? *

Yes No

Please provide some details drugs and/or alcohol are negatively impacting you... *

Do you require support with education, training and/or employment? *

Yes No

Other info..

If you don't know where what is happening for you fits, tell us more here. Is there anything else you think we should know about?

Last questions... nearly there!

Do you self harm? *

Yes No

Are you thinking about suicide? *

Yes No

Your privacy is important to us. This info will be kept confidential and used only to give you the best care possible

headspace Ballarat Privacy Policy

I have read and understand this Privacy Information

Yes

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.

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

Specific services NOT agreed to (please list):

Confidentiality Statement - Rights & Responsibilities

I am under 16 years of age, please call this person to obtain parental/guardian consent *

First Name Last Name

Their phone number *

Relationship to you [eg. parent, grandparent, legal guardian] *

Signed by the Parent/Guardian: 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. *

Clear

Signed by the Young Person: 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. *

Clear

Young person's details

Emergency contact

Reason for contacting headspace Ballarat

Last questions...nearly there!

Consent, Confidentiality, Your Rights & Responsibilities

CONSENT FOR COLLECTION, USE AND TRANSFER OF INFORMATION