self referral

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
Name *

First Name Last Name
Preferred name
Pronouns
Gender *
Country of Birth & Ethnicity *
Are you Aboriginal or Torres Strait Islander? *

Aboriginal Torres Strait Islander Both Aboriginal and Torres Strait Islander Neither Aboriginal not Torres STrait Islander
Are you connected to BADAC (Ballarat & District Aboriginal Co-operative)? *

Yes No
Preferred language
Interpreter required?

Yes No
Birth Date *

Day Month Year
Age *
Address *

Street Address

Street Address Line 2

City State

Postcode
Phone Number *
Contact Preference *

Phone call SMS
If you selected phone call as your preferred method of contact, is it OK if headspace Ballarat send you appointment reminders an other information via SMS?

Yes No
Email
example@example.com
Email
Medicare Number
Medicare Reference Number
Medicare Expiry
MM/YYYY
Health Care Card Number
Health Care Card Expiry
DD/MM/YYYY
Are you referring yourself? *

Yes No
emergency contact details

please note your emergency contact must be at least 18 years of age
Emergency contact's name *

First Name Last Name
Emergency contact's phone number *
Their relationship to you *
example: parent, legal guardian, friend,
reason for contacting headspace Ballarat

Please tell us what are the main issues that bring you to headspace Ballarat?
Greatest problem(s): *

0/200
Are there any general health issues limiting your day to day or social activities? *

Yes No
In just a few words please describe these general health issues *
Are drugs and/or alcohol having a negative impact on any areas of your health or lifestyle? *

Yes No
In just a few words please describe how drugs and/or alcohol are having a negative impact *
Do you require support with education, training and/or employment? *

Yes No
In just a few words please tell us what education, training and/or employment support would be helpful? *
Other Info:

0/150
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 privacy policy
I have read and understand this Privacy Information *

Yes
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
Specific services NOT agreed to (please list):
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
Name *

First Name Last Name
Their phone number *
Their relationship to you: *
Example: parent, legal guardian
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
Parent, legal guardian 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
Young person 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
Should be Empty:

self referral

young person's details

emergency contact details

reason for contacting headspace Ballarat

last questions...nearly there!

Consent, Confidentiality, Your Rights & Responsibilities