Family & Friends Referral Logo
  • 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 

    Young Person Self Referral Form

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

    Professional Referral Form

  • 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

  • Referrer Contact Information 

  • Young Person's Contact Information 

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  • Reason for referral to headspace Mildura

  • 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 headspace profile (this will also generate an invitation to create a headspace account) 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

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