Parent and Carer Peer Support - headspace Clinican Referral Form

Parent and Carer Peer Support headspace Ballarat Professional Referral
All fields marked with * are required and must be filled
Parent/Carer/Guardian's details
Parent/Carer Name*

First NameLast Name
Gender (male, female, trans, intersex, non-binary, other*
Preferred language
Address*

Street Address

Street Address Line 2

CityState

Post Code
Phone*
Email
Second parent/carer/guardian's contact details

(if applicable)
Second parent/carer name

First NameLast Name
Their phone number*
Young person's details
Name*

First NameLast Name
Their date of birth*

DayMonthYear
Date
Reason for contacting headspace Ballarat*

School refusalYoung person's behaviourYoung person's mental healthTech, social media and gamingRelationship supportDrug and alcohol issuesOther
Are they, the parent/carer/guardian currently linked with any other services?

YesNo
If yes, please detail other services here:
Referrer details
Referrer name*

First NameLast Name
Consent and Confidentiality
Please share this link with parent/carer/guardian:

https://form.jotform.com/headspaceballarat/peer-support-consent

A referral will be unable to proceed until the consent and confidentiality form has been received.

headspace Ballarat

Level 1, 20 Dawson Street North, BALLARAT CENTRAL VIC 3350

Phone: 5304 4777

Email: info@headspaceballarat.org.au
Should be Empty:

Parent and Carer Peer Support headspace Ballarat Professional Referral