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headspace Campbelltown Referral Form
headspace Campbelltown Referral Form
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Referral Forms
Important information regarding your referral, please read:
headspace is a service for young people between the ages of 12 to 25. We can only engage with young people who have provided consent to the referral. N.B. If Young Person is unable to provide informed consent due to mental state (e.g. psychosis), please contact us.
Please note that we are not and emergency service
. If the young person is at high or acute risk of suicide, please contact emergency services on 000 or attend your nearest hospital emergency department.
Receipt of the referral form does not indicate acceptance to the headspace services. Suitability of the referral will be determined following assessment with the young person.
To complete the referral, you must attach relevant assessment notes, discharge summaries and/or additional information.
If you have any queries pertaining to your referral, please phone the relevant site using the contact details above.
Consent for referral
Has the person provided consent
*
- required
Yes
No
*If person is unable to provide informed consent due to mental state (e.g. psychosis), please contact us.
Supports Recommended
Drug and Alcohol Support
Vocational Support
Physical Health Support
Assessment for short-term mental health intervention with headspace.
Does the YP have a Mental Health Care Plan?
Yes
No
Referrer details:
headspace will be corresponding with you using the below details. Please ensure that all details listed below are correct and legible.
Name of Referrer*
*
- required
Relationship to young person
Designation
Organisation
Service Address
Contact Number*
*
- required
Fax
Email*
*
- required
Young Person’s details
Name
Date of Birth
Age
Gender Identity
[Gender Identity]
Female
Male
Non-binary
Transgender
Intersex
I identify as another gender
I prefer not to say
Address
Suburb
Post code
Contact Number 1
Contact Number 2
Medicare No
Ref No
Expiry Date
Interpreter Required
Yes
No
Language
Assistance with Reading/Writing?
Yes
No
Parent/ Guardian / Next of Kin
* please note that if the Young person is aged 15 and under, we will require a parent or guardian to be documented on this form.
Name
Contact Number
Relationship to young person
Do we have permission to speak with the person identified?
Yes
No
Emergency Contact:
Name
Contact Number
Relationship to young person
Do we have permission to speak with the person identified?
Yes
No
Presenting Issues
Current presenting issues:
(please include duration, age of onset, and relevant pre-existing diagnoses)
Impact of problem on functioning:
(e.g. relationships/school/home/work)
Please indicate if there is any know family history of mental health conditions:
Please indicate if there is any know family history of mental health conditions:
Previous/current engagement with other services:
Previous/current engagement with other services:
Risk Factors
Please select (if any)
Suicide
Non-accidental self-injury
Harm to others
Extreme social withdrawal
Homelessness
Substance use
Accidental death
Non-compliance
Details
*IF risk is noted, please attach current safety plan
Support Preference
Preference for clinician (if any)
Female
Male
Preference for location (if any)
headspace Campbelltown
Oran Park library (only Tue and Thursday)
Consent
By submitting this form, the referrer agrees that the above information is true and accurate.
Yes
*
- required
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