Family & Friends Referral

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

If you are a Young Person (aged 12-25) referring yourself, please use the

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

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

Please check out this video..

Do you have the young person's consent for the referral?*

Yes; please continueNo; please discontinue and discuss with young person

Referrer Contact Information

Referrer Name:*

First NameLast Name

Referrer Phone Number:*

Relationship to Young Person: *

Young Person's Contact Information

Young Person's Name:*

First NameLast Name

Young Person's Preferred Name:

If the Young Person has been previously known by another name, please provide details:

Young Person's Pronouns:

If other, please specify:

Young Person's Gender:

Young Person's Age:*

Young Person's Date of Birth:*

Date

Young Person's Phone Number:*

Young Person's Email:

example@example.com

Young Person's Residential address:*

Street Address

Street Address Line 2

SuburbState

Post Code

Young Person's Postal address (if different to above):

Street Address

Street Address Line 2

SuburbState

Post Code

Is the Young Person of Aboriginal or Torres Strait Islander Origin?

What is the Young Person's main cultural background other than Australian or Aboriginal and Torres Strait Islander?

What is the Young Person's Country of Birth?

What is the Young Person's main language other than English spoken at home?

Does the Young Person require an interpreter?*

YesNo

If yes, please provide language required

Is the Young Person enrolled in school or employed?

YesNoUnknown

If yes, please provide name of school/workplace:

Please provide details of any current supports/services in place for the Young Person (i.e School Wellbeing, GP, Psychologist):

Young Person's Medicare Number:

*required for physical/sexual health clinic

Young Person's Medicare Reference Number:

*required for physical/sexual health clinic

Young Person's Medicare Expiry Date:

*required for physical/sexual health clinic

Does the Young Person have a NDIS Package?

YesNoUnknown

Young Person's Medications/Medical history (if any):

Young Person's Allergies (if any):

Reason for referral to headspace Mildura

Reason 1*

Reason 1 information*

Reason 2*

Reason 2 information*

Reason 3*

Reason 3 information

Other Information

Has the Young Person expressed thoughts of self harm or suicide?*

NoYes - self harmYes - suicide

Is the Young Person engaging in self harming behaviour?*

NoYesUnknown

Is the Young Person currently at risk of suicide?*

NoYesUnknown

Who would you like us to first contact to discuss the referral further?*

If other, please provide their details:

Who would you like to receive the SMS appointment reminder?

If other, please provide their details:

Thank you for your referral. A team member will be in touch with the 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 the safety/wellbeing of the young Person, 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 headpsace profile and electronic medical record for the Young Person. Records will be kept confidential and the Young Person's 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

I have read and understood the privacy information*

YesNo