Young Person Self Referral Logo
  • If you are a Young Person (aged 12-25) referring yourself, please use this Form

    If you are a Family or Friend referring a Young Person on their behalf, please use 

    Family & Friends Referral Form

    If you are a Professional Referrer (e.g Teacher, GP, Case Worker etc), please use 

    Professional Referral Form

  • Please note; headspace Mildura is not an acute mental health/crisis service. If you have immediate concerns regarding your safety/wellbeing, please contact Emergency Services on 000 or Mildura Base Public Hospital Mental Health Services on (03) 5022 3500

  • Contact Information 

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  • Emergency Contact 
    This is required if you are under the age of 16 years 

  • Reasons for contacting headspace Mildura

  • Thank you for your referral.  A team member will be in touch with yourself or your nominated contact within the next 3 business days.

    Please note; headspace Mildura is not an acute mental health/crisis service. If you have immediate concerns regarding your safety/wellbeing, please contact Emergency Services on 000 or Mildura Base Public Hospital Mental Health Services on (03) 5022 3500

  • Your privacy is important to us. To provide the best care, the information provided will be used to create a headspace profile (this will also generate an invitation to create a headspace account) and electronic medical record. Records will be kept confidential and your consent will be required to share any information. Please refer to our privacy policy and speak with a staff member if you have any questions or concerns:

    headspace Privacy Policy

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