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 that 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 continue No; please discontinue and discuss with young person

Referrer Contact Information

Referrer Name *

First Name Last Name

Referrer Phone Number *

Relationship to Young Person *

Young Person's Contact Information

Young Person's Name *

First Name Last Name

Young Person's Preferred Name

Young Person's Pronouns

Young Person's Gender

Young Person's Age *

Young Person's Date of Birth *

Date

Young Person's Phone Number *

Young Person's E-mail

example@example.com

Young Person's Residential address *

Street Address

Street Address Line 2

Suburb State

Post Code

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

Street Address

Street Address Line 2

Suburb State

Post Code

Is the Young Person enrolled in school or employed?

Yes No Unknown

If yes, please provide details

Please provide details of any current supports/services in place (i.e School Wellbeing, GP, Psychologist)?

Young Person's Medicare Number

Young Person's Medicare Reference Number

Young Person's Medicare Expiry Date

Does the Young Person have a NDIS Package?

Yes No Unknown

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

Young Person's Allergies (if any)

Is the Young Person? *

Aboriginal Torres Strait Islander Other

What culture does the Young Person identify with?

Reason for referral to headspace Mildura

Reason 1 *

Reason 1 information *

Reason 2 *

Reason 2 information *

Reason 3 *

Reason 3 information

Other Information

Is the Young Person engaging in self harming behaviour? *

Yes No Unknown

Is the Young Person currently at risk of suicide? *

Yes No Unknown

Your privacy is important to us. This information will be kept confidential and used only to provide the best care possible. Please refer to:

headspace Privacy Policy

I have read and understood the privacy information *

Yes No