Peer Support Self-Referral Form

Family and Carer Peer Support Referral

headspace Ballarat’s Family, Carer and Peer Navigator is available to support parents, carers, and family members of young people (aged 12-25 years) with mental and physical health concerns. This could include service navigation, exploring various support options, providing information, advice, and referral options.
Are you seeking to book an appointment for your young person at headspace Ballarat?
If so, please complete this referral form:
Young Person Referral Form

If you, as a parent or carer, are wanting to meet with our Family and Carer Peer Support Navigator then please continue with this Family and Carer Peer Support Referral.
All fields marked with * are required and must be filled
Parent/Carer/Guardian's details
Parent/Carer Name*

First NameLast Name
Preferred name
Pronouns
Gender (male, female, trans, intersex, non-binary, other*
Are you Aboriginal or Torres Strait Islander?

AboriginalTorres Strait IslanderBoth Aboriginal and Torres Strait IslanderNeither Aboriginal nor Torres Strait Islander
Preferred language
Interpreter required?

YesNo
Birth Date*

DayMonthYear
Date
Address*

Street Address

Street Address Line 2

CityState

Post Code
Phone*
Contact Preference*

Phone callSMS
If you selected phone call as your preferred method of contact, is it ok if headspace Ballarat sent you appointment reminders and other information via SMS?*

YesNo
Email
Second parent/carer/guardian's contact details

(if applicable)
Second parent/carer name

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

your child or dependent (nominal information required for the purpose of meeting headspace minimum data collection requirements)
Name*

First NameLast Name
Their date of birth*

DayMonthYear
Date
Their home suburb*
Reason for contacting headspace Ballarat*

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

YesNo
If yes, please detail other services here:
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
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 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
Confidentiality Statement - Rights & Responsibilities
Specific services NOT agreed to (please list):
Signed by the parent/carer/guardian*

Clear
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.
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:

Family and Carer Peer Support Referral

Parent/Carer/Guardian's details

Second parent/carer/guardian's contact details

Young person's details