Self Referral

For you to fill out. You can do it with the help of a family member or friend if needed... No worries!

Good on you for making it this far. This form won't take you very long. Some areas below are marked with a red asterisk and are essential to fill out. It is up to you whether you want to fill out the others.
Please note, headspace Bendigo is not a crisis response centre.

If you are in immediate risk, please contact Bendigo Psychiatric Triage on 1300 363 788, this number is contactable 24 hours a day, 7 days a week.
Are you between the ages of 12 to 25? *

Yes No
Are you referring yourself? *

Yes No
Have you seen anybody at headspace Bendigo before? *

Yes No
If you are under 16 years old, are your parents/carers aware of this referral? *

Yes No Not Applicable
If you are in school, which school do you attend? *
Are there any alerts you would like put on your file? For example; no parent contact, no letters home, etc.
Full name *

First Name Last Name
Preferred name
Date of birth *

Day Month Year
What do you identify as? *

Male Female
What are your preferred pronouns? *

Him/his She/her They/them Prefer not to answer
Address *

Street Number

Street Name

City/town State

Postcode
Phone number *
Email *
Medicare Card number
Reference number
Expiry
Health Care Card or Pension Card number
Expiry
Do you identify as Aboriginal or Torres Straight Islander? *

Yes No Prefer not to answer
Country of birth/ethnicity?
Preferred language
Do you need an interpretor? *

Yes No
Is there a family member or support person you would like us to speak to? *

Yes No
Name of family member/support worker
Contact phone number
Do you have a Doctor? *

Yes No
What is their name/practice?
Were there any other services previously involved? *
Youth Mental Health Team/CAMHS/Bendigo Health Mental Health Team/CASA/Anglicare/HAVEN/Youth Justice, etc.
Are there any other services currently involved? *
Youth Mental Health Team/CAMHS/Bendigo Health Mental Health Team/CASA/Anglicare/HAVEN/Youth Justice, etc.
Emergency contact
Full name *

First Name Last Name
Phone number *
Relationship to you *
What is your reason for contacting headspace Bendigo?
Please select the options below that match your situation. *

I'd like someone to talk to Things just aren't going very well Employment issues Interested in employment School issues Friendship issues Relationship issues Physical health Family issues Anxiety/stress Low mood Sexual health Grief and loss Trauma I need a mentor/coach Alcohol and other drugs Housing support Self harm Current suicidal thoughts I'm concerned about someone close to me
Tell us more here...
Is there anything else you think we should know about?

Please answer the below 5 questions: *

None of the time

A little of the time

Some of the time

Most of the time

All of the time

In the last 4 weeks, about how often did you feel nervous?

In the last 4 weeks, about how often did you feel without hope?

In the last 4 weeks, about how often did you feel restless or jumpy?

In the last 4 weeks, about how often did you feel that everything was an effort?

In the last 4 weeks, about how often did you feel so sad that nothing could cheer you up?

Your privacy is important to us. This information will be kept confidential and used only to give you the best care possible.

https://www.bchs.com.au/about/policies/privacy-policy
I have read and I understand this privacy information *

Yes No
Should be Empty:

For you to fill out. You can do it with the help of a family member or friend if needed... No worries!

Emergency contact

What is your reason for contacting headspace Bendigo?

Tell us more here...